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Complexity of care among pediatric patients in acute care settings: A systematic integrative review
(Elsevier B.V., 2026-07) García Ruiz, Rocío; Adamuz, Jordi; Ruiz Montaño, María; Barrientos-Trigo, Sergio
Background: The concept of complexity of care is well established in scientific literature; however, in pediatric populations, research has primarily focused on medical aspects, lacking a comprehensive approach that includes additional influencing factors. Purpose: This study aimed to identify the evidence on complexity of care among pediatric patients attending pediatric acute care settings. Methods: An integrative review was conducted the PRISMA guidelines (PROSPERO registration: CRD42023469426). The search included articles published up to July 2025 in PubMed, CINHAL, Scopus, and WOS. Both the quality and internal validity of the studies included were independently assessed by two reviewers. Results: Twenty-two articles were analysed, identifying 48 complexity-related factors and 39 assessment scales. Findings were grouped into four thematic categories, within each of which the following key complexity factors were identified: A) Clinical aspects of pediatric patients, such as diagnosis, patient type, and clinical stability; B) Environmental factors, particularly family involvement; C) Care provider aspects, such as direct/indirect nursing activities and workload; D) Organisational elements, especially nursing staff experience. Conclusions and implications: This review expands the understanding of complexity beyond patient pathology. It underscores the need for further research to explore healthcare professionals' perceptions of complexity and examine how the identified factors influence health outcomes. Developing integrated assessment tools may enhance care planning and resource allocation in pediatric settings.
ERAS Implementation fidelity, care complexity, and postoperative outcomes in oncological colorectal surgery: A real-world observational study
(MDPI, 2026-05-29) Jerez González, José Antonio; Hidalgo Blanco, Miguel Ángel; Puig Llobet, Montserrat; Adamuz, Jordi; Juvé Udina, Eulàlia; Polushkina-Merchanskaya, Oliver; Miguel Huguet, Bernat; Mariscal Cabeza, Mireia; Moreno Arroyo, M. Carmen
Background: Enhanced Recovery After Surgery (ERAS) programmes are structured perioperative care pathways in which clinical outcomes are closely linked to the degree of implementation fidelity. However, the interaction between ERAS adherence, care complexity, and postoperative outcomes in real-world settings remains insufficiently explored. Objective: To evaluate the association between ERAS adherence and postoperative length of stay in oncological colorectal surgery and to analyse whether Care Complexity Individual Factors (CCIFs) influence this relationship. Methods: A retrospective observational cohort study was conducted in two university hospitals in Barcelona, including 90 adult patients undergoing elective colorectal cancer surgery (2022). ERAS adherence was assessed globally and by phase (pre-, intra-, and postoperative) using structured indicators. CCIFs were classified into five domains. Associations between adherence, care complexity, and outcomes were analysed using bivariate methods. Results: Overall adherence was 64%. Higher adherence was associated with shorter hospital length of stay (median 4 vs. 5 days; p = 0.033) and greater compliance with expected length of stay (37.8% vs. 17.0%; p = 0.047). Adherence varied across perioperative phases, with higher compliance in the preoperative phase and lower compliance postoperatively. Care complexity was high (mean CCIF 2.62) and was not significantly associated with adherence or compliance with expected length of stay. Conclusions: Higher ERAS adherence is associated with shorter hospital stay in oncological colorectal surgery within a real-world context. These findings support the importance of implementation fidelity across the perioperative pathway. Further research incorporating multivariable analyses and patient-centred outcomes is needed to better understand the interaction between care complexity and recovery trajectories.
Intervenciones enfermeras para disminuir la sobrecarga de cuidadores informales. Revisión sistemática de ensayos clínicos.
(Servicio de Publicaciones, Universidad de Murcia, 2022-10-01) Tinoco Camarena, José Manuel; Hidalgo Blanco, Miguel Ángel; Daifuku Sansano, Nara; Lluch Canut, Ma. Teresa; Raigal Aran, Laia; Puig Llobet, Montserrat
Introducción: Los cuidadores informales suelen ser miembros de la familia de un paciente, que conducen a la dependencia del paciente del cuidador. Esto puede resultar en perturbaciones en la calidad de vida de los cuidadores. Para abordar los efectos negativos de la atención informal, existen varios tipos de intervenciones eficaces para reducir las visitas médicas tanto de los cuidadores informales como de los pacientes a su cargo. Objetivo: Examinar la eficacia de las intervenciones de enfermería existentes diseñadas para reducir la sobrecarga del cuidador informal de personas con enfermedad crónica. Metodología: Diseño: Revisión sistemática. Fuentes de datos: Bases de datos como Pubmed (MEDLINE), Embase, The Cochrane Library y CINAHL fueron buscadas usando palabras clave sobre intervenciones de enfermería en cuidadores familiares. Los artículos publicados entre 2014-2019 fueron recuperados y sometidos a análisis de datos y síntesis de conocimientos Método de revisión: Dos revisores seleccionados de forma independiente. La evaluación de la calidad se basó en la lista de verificación de evaluación de declaraciones prisma. La síntesis es narrativa. Resultados: Noventa y cinco estudios fueron examinados en su totalidad, y setenta y siete fueron descartados por no proporcionar resultados adecuados. El recuento final de artículos incluidos en esta revisión fue de dieciocho que fueron todos ensayos clínicos aleatorizados. Conclusiones: El análisis de los diferentes estudios muestra eficacia en la reducción de síntomas como estrés, ansiedad, depresión o incluso necesidades insatisfechas. Las intervenciones más eficaces para reducir la carga del cuidador fueron las visitas domiciliarias y las intervenciones psicoeducacionales, tanto individuales como grupales.
The ethical relevance of nursing care in euthanasia and assisted suicide La relevancia ética del cuidado enfermero en la eutanasia y el suicidio asistido
(Elsevier, 2021-08-26) Busquets Surribas, Montserrat
La reciente aprobación de la Ley orgánica 3/2021, de regulación de la eutanasia, reconoce que en España las personas que así lo deseen, y cumplan determinados requisitos, puedan solicitar la ayuda a morir ampliándose, de esta forma, las prestaciones a las que puede acogerse una persona al final de su vida1. A los cuidados paliativos, que son la oferta profesional en esta realidad vital, se añade la posibilidad de que personas que experimentan una situación de alto sufrimiento por una enfermedad o problema de salud puedan, a petición propia, recibir ayuda para adelantar su muerte.
O direito à educação inclusiva e a acessibilidade multíplice no Ensino Superior: a legislação brasileira e a perspectiva de Pierre Bourdieu
(Instituto Federal de Educação, Ciência e Tecnologia do Piauí, 2026-05-13) Marinho, Jaqueline Luvisotto; Rodríguez-Martín, Dolors; Chaveiro, Neuma
Considerando que a legislação brasileira assegura o direito à Educação Inclusiva, mas o Ensino Superior mantém estruturas históricas de distinção social e insuficiências expressivas em condições de acessibilidade para pessoas com deficiência, este artigo objetiva analisar a legislação brasileira sobre o tema em articulação com a perspectiva sociológica de Pierre Bourdieu. Para tanto, foi desenvolvida pesquisa qualitativa, de cunho teórico e documental, utilizando a Análise de Conteúdo do aparato normativo federal vigente, acerca da temática da Educação Inclusiva, Educação Especial, Ensino Superior e direito à educação de pessoas com deficiência, em diálogo com concepções sociológicas de Pierre Bourdieu sobre o campo educacional, incluindo as de <em>habitus</em>, capital cultural e educacional, distinção social e violência simbólica. Desse modo, compreende-se que, apesar da solidez da legislação, o Ensino Superior frequentemente resiste a mudanças essenciais, tratando a acessibilidade como mera obrigação burocrática, focada na integração por ações de Educação Especial demandistas, na normalização do estudante e na padronização das ações pedagógicas, e que isso se torna amparado por interpretações normativas não fundamentadas na perspectiva da Educação Inclusiva e da inclusão educacional plena. Conclui-se que a implementação efetiva do direito à Educação Inclusiva exige práxis reflexiva e crítica e a ruptura com a conservação das desigualdades acadêmicas, tornando a acessibilidade multíplice, transformando a cultura institucional e anulando as barreiras sociais institucionalizadas.
Ensino superior e inclusão educacional de pessoas com deficiência: perspectivas de garantias de direitos em normativas internacionais
(Arché Editora, 2026-05-07) Marinho, Jaqueline Luvisotto; Chaveiro, Neuma; Rodríguez-Martín, Dolors
O estudo analisa as garantias de direito à educação no ensino superior para pessoas com deficiência sob a perspectiva das normativas internacionais de direitos humanos. Historicamente, o acesso a essa modalidade de ensino tem sido marcado por barreiras complexas e um capacitismo estrutural que, amparado em uma perspectiva biomédica excludente, exige um padrão meritocrático de desempenho e culpabiliza o indivíduo por dificuldades de adaptação. Para compreender, diante desse cenário, como as normativas internacionais de direitos humanos configuram a concepção de acesso ao ensino superior para pessoas com deficiência e a perspectiva de garantia de direito à educação nessa modalidade de ensino, foi desenvolvida pesquisa qualitativa de característica documental, com análise de conteúdo de sete marcos normativos internacionais fundamentais. Os resultados evidenciam a transição paradigmática do deslocamento da visão biomédica e meritocrática para o modelo biopsicossocial e de direitos humanos, fundamentado na dignidade e equidade. Os documentos analisados, que possuem elevada relevância legislativa e força interpretativa no Brasil, reforçam que o acesso pleno deve englobar concomitantemente as dimensões de disponibilidade, acessibilidade, aceitabilidade, adaptabilidade e responsabilidade, demandando implementações de ações contrapostas ao capacitismo estrutural e institucional e para minimização das dificuldades de acesso em decorrência de barreiras sociais, atitudinais e pedagógicas. Com isso, impõe-se a superação da mera integração superficial e segregadora em favor de uma real inclusão educacional, exigindo a flexibilidade e adaptação à diversidade dos alunos. Conclui-se, elaborando um arcabouço jurídico-teórico-ético, que a garantia de direitos no ensino superior transcende a matrícula, demandando a eliminação de fechaduras institucionais para assegurar a permanência, o aprendizado e a participação plena, alinhando-se ao princípio global de não deixar nenhum ser humano para trás.
Realidades transcontinentais da saúde mental em pessoas surdas: revisão sistemática
(2026-04-21) Galvão, Marcus Vinicius Alves; Chaveiro, Neuma; Duarte, Soraya Bianca Reis; Pereira, Mirley Galvão; Nogueira, Yanley Lucio; Rodríguez-Martín, Dolors
Objetivo: Sintetizar as evidências sobre as condições de saúde mental, os fatores de risco e o acesso aos serviços entre pessoas surdas no Brasil e na Espanha. Métodos: Revisão sistemática registrada no PROSPERO (CRD420251001388), realizada nas bases LILACS, SciELO, Scopus e Embase com os descritores deaf OR "mental health" AND Brasil OR Espanha de estudos observacionais. A busca recuperou 3362 estudos; após a exclusão de duplicatas e aplicação dos critérios de elegibilidade, 9 estudos compuseram a revisão. Resultados: Os achados evidenciam diferentes formas de vulnerabilidade e adoecimento na população surda. Tanto no Brasil quanto na Espanha as evidências apontaram barreiras significativas do surdo no acesso e cuidado em saúde, além de problemas emocionais, psicolinguísticos, comprometimento no bem-estar físico e social. Considerações finais: Torna-se essencial a implementação de políticas públicas inclusivas, a formação de profissionais capacitados e o desenvolvimento de pesquisas com amostras representativas, a fim de promover equidade no cuidado à saúde mental da população surda.
Percepción de la gamificación en la educación médica: un estudio en estudiantes de Medicina en Paraguay
(2025-09-29) López Esquivel, Nelson Gabriel; León Castelao, Esther; Aveiro-Róbalo, Telmo Raul
Introducción: la gamificación, entendida como la aplicación de dinámicas de juego en entornos no lúdicos, surge como una estrategia educativa innovadora para potenciar la motivación y la participación estudiantil. En la formación médica, este enfoque resulta particularmente útil, debido a la alta exigencia académica y la necesidad de integrar conocimientos teóricos y prácticos de manera significativa. Objetivo: analizar la percepción de estudiantes de Medicina sobre la gamificación en su proceso formativo. Método: estudio transversal y cuantitativo realizado en 331 estudiantes de Medicina de la Universidad del Pacífico, Paraguay, mediante cuestionarios específicos sobre el perfil de jugador, escala PAMLES, y una encuesta sobre experiencias gamificadas en el taller de habilidades médicas. Resultados: la mayoría de los estudiantes valoró positivamente la gamificación, resaltando beneficios motivacionales y de aprendizaje. Algunas percepciones negativas incluyeron dificultades para el trabajo en equipo y sensación de pérdida de tiempo. Discusión: la gamificación representa una herramienta pedagógica valiosa en la educación médica, con potencial para personalizar la enseñanza y aumentar el compromiso estudiantil. Su aplicación debe considerar perfiles de jugador, contexto institucional y posibles resistencias.
Empodérate la mente: estudio con metodología mixta de un grupo psicoterapéutico con técnicas corporales y de autodefensa en mujeres con diagnóstico de salud mental y antecedentes de violencia de género
(Asociación Española de Neuropsiquiatría, 2026-04-22) Luque-Tintó, Alba; Ventura Fuentes, Cristina; Viejo García, Rodrigo; Estébanez Elguezabal, María; Rodríguez-Martín, Dolors
Introducción: La violencia de género en mujeres con trastorno mental grave (TMG) es un problema prevalente y poco visibilizado que se asocia a trauma complejo, vulnerabilidad y fragmentación asistencial. Objetivo: Evaluar la eficacia de Empodera tu mente, intervención psicoterapéutica grupal integrativa que combina psicodrama, autodefensa feminista y empoderamiento corporal, en mujeres con TMG que han sufrido violencia de género. Método: Estudio cuasi experimental mixto pre–post sin grupo control (n=39). Intervención de 13 sesiones (90 min) en grupo cerrado semanal. Medidas: AF-5, SCL-90 R y Escala de Asertividad de Rathus; entrevistas semiestructuradas pre y post. Resultados: Mejoró el autoconcepto físico y disminuyeron síntomas depresivos, con mayor conciencia emocional. El análisis cualitativo mostró cambios en autoconcepto corporal, afrontamiento y proyección de futuro. Conclusiones: La intervención integrativa con autodefensa y reconexión corporal mejora empoderamiento y variables clínicas relevantes en mujeres con TMG y violencia.
Intensive Care Unit Nurses' Perceptions of Work Environments: A Cross- Sectional Study From Five European Counties
(John Wiley & Sons, 2026-02-27) Georgiou, Evanthia; Mpouzika, Meropi; Llauradó Serra, Mireia; Friganovic, Adriano; Sabou, Adrian; Gutysz-Wojnicka, Aleksandra; Constantinescu-Dobra, Anca; Alfonso-Arias, Cristina; Curado Santos, Estel; Slijepcevic, Jelena; Cotiu, Madalina-Alexandra; Penar Zadarko, Beata; Rezic, Sladana; Dobrowolska, Beata; Kyranou, Maria
Aim: To explore intensive care nurses' perceptions of their work environments at the unit and organisational levels according to the American Association of Critical Care Nurses standards, their impact on care quality, national differences, and demographic associations. Design: Cross- sectional study using a survey design. Methods: Study conducted between January 2021 and April 2022, using a convenience sample of intensive care unit nurses across Cyprus, Spain, Croatia, and Poland, Romania. The Critical Elements of a Healthy Work Environment Scale (CEHWES) developed by the American Association of Critical Care Nurses and cross- culturally adapted by the authors was used, which included four sections, including sociodemographic data and a total of 50 questions. The core section of the tool comprised 16 questions using Likert- type response (1—strongly disagree—4 strongly agree). Perception of fulfilment of healthy work environment standards was calculated using the aforementioned Likert- type scale. Results: A total of 1183 nurses participated reporting moderate perception of fulfilment of the standards, with mean scores ranging from 2.6 to 2.8. Skilled communication and effective decision making were the highest rated. 56% (n = 662) reported awareness of some standards and while 25.8% (n = 305) reported full or significant implementation in their unit. Significant differences related to the perception of all standards were observed across countries. Implementation of the standards was significantly associated with higher quality of care having better perception when standards were fully implemented.
Validation by expert groups of the conceptual and structural dimensions in the AcompdogSMP+ nursing program: a dog-assisted therapy to promote positive mental health
(Wiley, 2025-02-18) Balaguer-Sancho, Judith; Puig Llobet, Montserrat; Tinoco Camarena, José Manuel; Agüera, Zaida; Lluch Canut, Ma. Teresa; Moreno Arroyo, M. Carmen
Introduction: AcompdogSMP+ is a nursing program for the promotion of positive mental health using a dog-assisted therapy for individuals with severe mental disorders. Objective: To validate the content validity of the four conceptual and the three structural dimensions that shape AcompdogSMP+. Design and Methods: Three expert groups with a total of 28 participants were convened, associated with the three core areas of the program (i.e., the multifactorial model of positive mental health, the “animal-assisted therapy” nursing interventions taxonomy, and the animal-assisted therapy as a complementary intervention model). The qualitative data were analyzed using an existing text analysis method, and the notes taken by the moderator and an assistant. The quantitative data were analyzed through the content validity index (CVI) for 68 different items that made up the seven dimensions of the AcompdogSMP+ program, through the data obtained from an ad hoc Likert-type scale. Results: The degree of agreement of the experts was complemented with the values obtained in the results of the quantitative data. CVI values of virtually all items were excellent (greater than 0.78). Only one item had a CVI considered good (I-CVI = 0.68). The values of the Scale Content Validity Index (S-CVI/Ave) ranged from 0.88 to 1.00, with most of the indices being excellent (above 0.90). Conclusion: The results supported the content validity of the seven dimensions, of the AcompdogSMP+ program. The validation might allow its clinical validation, through its implementation in healthcare practice, as well as the evaluation of its effectiveness. Implication for Practice: To our knowledge, this is the first animal-assisted therapy nursing program to promote positive mental health validated by expert judgment. By confirming the content validity of each dimension, robustness and empirical evidence is given to integrate the program into clinical practice with confidence, offering a structured and complementary intervention aimed at improving mental health outcomes and overall well-being of patients with severe mental disorders. This could lead to greater patient engagement, improved therapeutic outcomes, and a more holistic approach to mental health.
Implementation of good humanization practices in a pediatric intensive care unit: An audit and feedback quality improvement study
(Elsevier B.V., 2026-05-08) García-Fernández, Javier; Delgado-Hito, Pilar; Segura Encinas, Vanessa; Rosell Ruiz, Noemi; Romero García, Marta
Objectives: To describe the implementation of the Manual of Good Practices in Humanization in Pediatric Intensive Care Units through an Audit and Feedback strategy and examine observed changes in compliance in a high-complexity unit. Methods: A comparative longitudinal observational study (pre–post) was conducted from January to December 2025 in a high-complexity pediatric intensive care unit in Spain. The implementation process followed a 12-month Audit and Feedback cycle structured in four phases: baseline audit, participatory prioritization, decentralized protocol development, and final evaluation. Compliance with 127 evaluable good practices was measured, and 95% confidence intervals were calculated using the Wilson score method. Results: Baseline compliance was 69.3% (88/127; 95% CI: 60.8–76.6). At final evaluation, overall compliance reached 72.4% (92/127; 95% CI: 64.1–79.5), representing an absolute increase of 3.1 percentage points (95% CI: −7.9 to +14.2). The prioritized strategic lines of Communication and Patient well-being showed gains of 14.3 and 8.3 percentage points, respectively; however, overlapping confidence intervals indicate that these changes cannot be distinguished from sampling variability. Among unimplemented practices, 87.2% required organizational and training actions, while 12.8% required direct financial investment. Conclusions: This implementation-focused quality improvement study suggests that Audit and Feedback may be feasible for structuring the monitoring, prioritization, and adoption of humanization practices in a high-complexity pediatric intensive care unit. Modest quantitative changes and organizational outputs were observed, but these findings cannot be considered evidence of intervention effectiveness. Future cycles should assess sustainability and incorporate patient-and family-level outcomes.
The role of the ethics expert in Spanish legislation on euthanasia and mental health
(Springer Nature, 2025-06) Ramos Pozón, Sergio
This article examines the assessment of mental capacity in the context of euthanasia,particularly when requested by patients with mental illnesses. It proposes a holisticalternative approach to the traditional functional model, arguing that the latter isinsufficient to capture the complexity of these patients’ decisions. Using approachesbased on narrative, hermeneutic, and dialogical ethics, it offers an evaluation thatconsiders the patient’s life story, values, and context. Shared decision-making andempathy are identified as fundamental components to ensure informed and consensualdecisions, promoting an environment of respect and mutual understanding. Thearticle reviews Spanish legislation on euthanasia, highlighting the need to includemedical ethics experts in the Guarantee and Evaluation Commissions. These expertsprovide a comprehensive ethical perspective essential for addressing the ethicalcomplexities in euthanasia requests and ensuring fair decisions that reflect the patient’strue will. It recommends reviewing and expanding current protocols, as wellas including continuous ethics training to improve medical practice in this context.The conclusions suggest that an assessment of mental capacity based on ethicalprinciples and an integrated narrative can significantly improve medical practiceand decision-making in euthanasia, especially for these patients. Furthermore, theinclusion of ethics experts in the commissions can provide a more humane andjust perspective, ensuring that decisions respect the patient’s dignity and autonomy.
Improving family-centered care in intensive care units: participatory action research to design and implement changes in nursing care
(Wiley, 2026-05-14) Cueva Ariza, Laura de la; Delgado-Hito, Pilar; Lluch Canut, Ma. Teresa; Benito-Aracil, Llúcia; Via-Clavero, Gemma; Cuzco, Cecilia; Romero García, Marta; Martínez Momblán, Ma. Antonia
Background: It is imperative to take care of the critically ill patient's family and meet their needs. Although there are evidence-based recommendations for doing so, their implementation is not widespread because changing the culture of care is difficult. Aim: To implement evidence-based changes in care for family members of critically ill patients in a tertiary hospital using a reflexive and participatory process and to assess their effects. Study Design: Participatory action research. A homogeneous theoretical sample of nurses from three intensive care units in a tertiary care hospital, with ≥ 5 years' experience and willingness to reflect on and critique their practice. Data were gathered through participant observation, documentary analysis, multilevel discussion groups and field diaries and a thematic analysis was performed. Results: Based on the identification of the causes and consequences of a variable and non-generalised approach to family care, a multicomponent, evidence-based set of strategies was designed and implemented. Subsequently, participants perceived important benefits: family members appeared more satisfied, collaborative and less anxious; patients reported feeling safer, emotionally supported and experiencing reduced stress, agitation or disorientation; and nurses perceived greater visibility of nursing care alongside enhanced professional satisfaction. Conclusions: Reflexivity, consensus and the active participation of healthcare professionals facilitated the change that ultimately enabled the genuine implementation of evidence-based recommendations. The training of the care team, the contextualisation of the strategies and the progressiveness of the process were key in generating change, reducing the variability of practice and leading to key benefits. Relevance to Clinical Practice: The interventions provide an adaptable guide for ICUs to implement and evaluate a multifocal approach to family-centred care, enhancing its benefits.
Clinical trial protocol for continuous glucose monitoring in critical care at Hospital Clinic of Barcelona (CGM-UCI23)
(Wiley, 2024-10-28) Pañero-Moreno, Marc; Guix Comellas, Eva Maria; Villamor Ordozgoiti, Alberto
Background: Hyperglycaemia is common in intensive care units (ICUs), with a prevalence of up to 86.2%, increasing mortality. Technology has evolved towards continuous glucose monitoring (CGM), and its use in ICUs began especially during the coronavirus pandemic (COVID-19). Various studies have evaluated the reliability of CGM, indicating that it is safe for use in critically ill patients. Aim: The aim of this study was to compare the use of CGM with point-of-care glucose (POC-G) testing in ICU. Specific objectives include evaluating the glycaemic control, the frequency of POC-G measurements, the incidence of hyperglycaemia, hypoglycaemia and morbidity and mortality at 90 days. Study Design: An experimental, controlled and randomized clinical trial with a singleblind design will be conducted at Hospital Clinic of Barcelona (HCB). A sample size of 376 participants will be recruited and randomly assigned to two groups: an experimental group, where glycaemic management will be based on CGM; and a control group, where glucose will be managed through POC-G testing, with a blinded CGM. Results: The primary variable considered will be time in range (TIR), with secondary outcomes including, time above range (TAR), time below range (TBR), number of POC-G measurements, incidence of hyperglycaemia and hypoglycaemia, and mortality. Hypothesis testing will use the Kolmogorov–Smirnov test to assess data normality, with appropriate statistical tests applied, considering a p-value <.05. Relevance to Clinical Practice: The results obtained will help us understand the impact of CGM on critically ill patients. CGM could potentially reduce the workload of nurses and improve the efficiency of decision-making by the ICU team, enabling early identification and treatment of glucose complications, thereby enhancing safety. Patient safety, a reduction in patient fingerstick and a decreased care burden are the criteria that add value to this research.
Impact of Prolonged Ischemia and Fixation on the Immunohistochemical Expression of PD-L1 in Non-small Cell Lung Cancer Specimens
(Xia & He Publishing, 2026-03-18) Barberà, Angels; González, Juan; Martin, Montserrat; Fernández, Pedro L.; Oriol, Albert; Martínez Soler, Fina; Santalucía Albi, Tomàs; Mate, José L.
Humanized antibodies targeting PD-1 or PD-L1 are established standards of care for non–small cell lung cancer (NSCLC), and there seems to be a correlation between tissue expression of PD-L1 and response rate in patients.1,2 Most of the analytical challenges in the immunohistochemical evaluation of PD-L1 expression have been extensively analyzed.3 However, preanalytical issues have been scarcely explored. The impact of prolonged ischemia and tissue fixation on PD-L1 false-negative cases has been established, and the fixation time window to obtain optimal results in control tissue,4 most commonly tonsil, has also been determined.5,6 Extrapolation of such results to specific tumor tissues should be made with caution, as tonsil tissue is less affected by variability than tumor samples. Heterogeneity of expression may preclude the adequate interpretation of suboptimally processed samples.7 Moreover, small-size samples, including bronchoscopic biopsy specimens or cytology blocks, may be even more sensitive to prolonged prefixation periods.8 The main objective of this study was to determine the proportion of routine samples processed within acceptable preanalytical times and to evaluate the extrapolatability to NSCLC samples of ischemia and fixation time limits established for the assessment of PD-L1 expression in control tissue. We retrospectively reviewed consecutive and unselected samples received at a referral pathology unit, selected from the unit database over a one-year period. Samples were eligible if they included an NSCLC diagnosis and PD-L1 determination. Sample processing was uniform across all the evaluated period (see File S1). Age, gender, biopsy site and method, processing method, histological subtype, and PD-L1 results, including proportion and intensity of positive cells, were recorded for each patient (Table 1, Table S1). Samples were considered PD-L1 positive if at least 1% of tumoral cells were positive, although other cut points were also explored. Based on previous studies in control tissue, an optimal preanalytical time of up to 72 h was defined. Time from surgical procedure to laboratory admission and time from laboratory arrival to end of fixation were obtained from the traceability system, and their addition was considered the full preanalytical time. Bivariate analysis was performed to assess significant relationships between the duration of the preanalytical process and PD-L1 results. The R-package version 3.0.1 was used for all statistical analyses (R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/ ). The study was approved by the the Comitè d’Etica de la Investigació amb medicaments, Hospital Universitari Germans Trias i Pujol (PI-18-072 approval number) and performed in adherence to the STROBE guidelines.
Improving Emergency Department Staff Satisfaction Through Lean Thinking: Evidence From a Mixed Study
(John Wiley & Sons, 2026-03-20) Pastor-Puigdomènech, Andrea; Sánchez Sánchez, Miguel; Font Cabrera, Cristina; Fabrellas i Padrès, Núria; Benito-Aracil, Llúcia; Guix Comellas, Eva Maria
Aims: To compare job satisfaction among emergency department staff before and after the implementation of Lean Thinking and to explore staff experiences regarding this methodology, identifying associated satisfaction factors. Background: Lean Thinking, originally developed in the automotive industry, is increasingly applied in healthcare to optimise processes and improve patient care. Staff engagement and perceptions are key determinants of successful implementation. Methods: A mixed-methods pre–post design was conducted. The Font-Roja job satisfaction questionnaire was administered preintervention and 1 year postimplementation, and semistructured interviews were conducted with emergency department staff. Results: Overall job satisfaction increased (3.31–3.43; p = 0.029), with significant improvements in job monotony (3.30–3.64; p = 0.038) and physical work setting (3.31–3.75; p = 0.007). Qualitative analysis revealed ten subthemes including improved organisation and teamwork, a more methodical workflow, the need for adaptation, and concerns about potential dehumanisation. Conclusion: Lean Thinking increased job satisfaction in the emergency department, favouring structured work and better interprofessional communication. The professionals supported its continuity and highlighted the need for follow-up meetings and constant improvements.
Prognostic value of jugular, pulmonary and inferior vena cava ultrasound in decompensated heart failure in primary care
(Elsevier B.V., 2026-01-10) Cendrós Cámara, Victoria; Navas, Elena; Miranzo, Esther; Muñoz, Miguel A.; Pirretas, Laura; Pifarrè, Leila; Inzoli, Marco; Enjuanes, Cristina; Sierra, Verónica; Roger, Ana; Caballol Angelats, Rosa; Verdú Rotellar, Jose María
Background: Multiparametric ultrasound combining pulmonary and venous assessment (inferior vena cava [IVC] and internal jugular vein) is a feasible tool for characterizing hemodynamic congestion in patients with heart failure (HF) managed in Primary Care. Objective: To evaluate the short-term prognostic value of pulmonary and venous ultrasound in patients with decompensated HF treated with intravenous diuretics in community settings. Methods: Prospective cohort study including patients with decompensated HF attended between April 2024 and September 2025 across seven Primary Care teams of the Catalan Health Institute. Clinical, analytical, and ultrasound variables (IVC, jugular vein, and 8-zone lung ultrasound) were recorded. The primary outcome was a composite of death, HF hospitalisation, or new intravenous treatment within seven days. Results: A total of 197 patients were included (56.4 % women; mean age 84.7 ± 7.5 years). Signs of venous and pulmonary congestion were frequent at inclusion. Within seven days, 14.8 % of patients experienced the composite outcome. In multivariate analysis, IVC collapsibility <25 % (OR 3.70; 95 % CI 1.13–14.53; p = 0.039) and prior heart failure hospitalisation (OR 4.47; 95 % CI 1.48–14.10; p = 0.008) were independently associated with events, whereas lung and jugular ultrasound parameters were not. Conclusions: Multiparametric ultrasound performed in Primary Care allows identification and quantification of hemodynamic congestion in decompensated HF. Among evaluated parameters, only IVC collapsibility showed independent short-term prognostic value, supporting its integration into community-based risk stratification models.
Barriers and facilitators for mental-health professionals in the management and implementation of advance directives
(Elsevier, 2026-04-01) Ramos Pozón, Sergio; Falcó Pegueroles, Anna M. (Anna Marta); Poveda-Moral, Silvia; Andrés Mora, Hilari; Fabregat Marcos, Raquel; Mir Abellán, Ramon; Baladón Higueras, Luisa; Román Maestre, Begoña; Robles del Olmo, Bernabé; Garrido Aguilar, Eva María
Background: The Advance Directive (AD) serves as a fundamental legal and ethical instrument for safeguarding patient autonomy, ensuring that clinical decisions align with individual values when decision-making capacity is compromised. Despite the established legal framework in Spain since 2002, its practical implementation within mental health services remains largely under-researched. The objective of our study is to describe the barriers and facilitators perceived by mental-health professionals regarding the clinical management and implementation of the Advance Directive (AD). Methods: A descriptive, cross-sectional study was executed between December 2022 and March 2023 at Parc Sanitari Sant Joan de D´eu (Barcelona, Spain). The sample comprised 215 healthcare professionals across various disciplines—including nursing, psychiatry, psychology, and social work—representing a participation rate of approximately 20% of the 1035 eligible institutional staff. Findings: Results reveal a profound discrepancy between theoretical appraisal and clinical practice. Although 96.7% of professionals acknowledge the utility of the AD, practical engagement remains residual: only 20.0% of participants report direct experience with a patient's document. Critical operational barriers were identified, as 74.4% of respondents were unfamiliar with procedures for retrieving an AD from the official registry. Furthermore, 71.6% of professionals perceive an absence of adequate technical or administrative resources provided by their institution. Conversely, facilitators are rooted in ethical commitment; 88.3% maintain that a patient's anticipatory wishes should be respected even when they conflict with clinical advice. Conclusions: Findings underscore a significant gap between the ethical-legal ideal of autonomy and its clinical execution within the Spanish mental health context. Positive professional attitudes are insufficient without robust systemic support. Effective implementation necessitates a multidimensional strategy: strengthening specialized continuing education, streamlining access protocols within electronic health records, and fostering institutional policies that prioritize patient-centered psychiatric care.
Coercive measures in disability and mental health care services: Mechanical restraints from a bioethical and legal perspective in Spain
(Elsevier, 2025-01-16) Ramos Pozón, Sergio; Román Maestre, Begoña; Blánquez Gómez, Blas
This article explores the use of coercive measures, particularly mechanical and pharmacological restraints, indisability care settings and mental health services from a bioethical perspective, focusing on how these practicesimpact the human rights of individuals with mental disorder, focusing on how these practices impact the humanrights of individuals with mental disorders. A robust bioethical framework is presented, advocating for principlesof autonomy, beneficence, non-maleficence, dignity, dialogical justice, distributive justice, and vulnerability.These principles are integrated to reframe interventions and promote respect for patient rights. The articleprovides a detailed account of the legal framework governing these practices in Spain, addressing both nationaland regional legislation, and emphasizing its significance in protecting human rights. Finally, practical recommendationsare offered, which have proven effective in significantly reducing the need for coercive interventions.The article concludes by advocating for a transformation in clinical practices, promoting dignifiedand respectful care in line with a human rights framework, and moving away from unnecessary coercivemeasures.

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