Medical Sciences

Background/Objectives: Healthcare waste is commonly framed in terms of material overuse, duplication, inefficient spending, and low-value care. However, less is known about how waste is understood within inpatient nursing practice, particularly from a nursing management perspective. This study explored how nurse managers conceptualised waste in medical inpatient nursing care and how these perceptions related to the loss of nursing value. Methods: A qualitative descriptive study with an interpretive orientation was conducted using semi-structured individual interviews with nine nurse managers from medical inpatient units within the public hospital network of the Autonomous Region of the Azores, Portugal. Interviews were audio-recorded, transcribed verbatim, and analysed using qualitative content analysis with inductive open coding. Reporting was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results: Four interconnected themes were developed: loss of clinical contact time, underutilisation of nursing expertise, constrained relational and individualised care, and limited visibility of nursing-sensitive outcomes. Participants associated these forms of value loss with staffing pressures, fragmented workflows, non-interoperable information systems, duplicated documentation, logistical demands, routinised practices, and limited outcome measurement. These conditions were perceived to redirect nursing time away from patients, restrict the mobilisation of specialist and experiential knowledge, constrain therapeutic and individualised care, and reduce the organisational visibility of nursing contributions to patient outcomes. Conclusions: Waste in inpatient nursing care may extend beyond material and operational inefficiency to include losses in clinical time, professional expertise, and relational care, together with reduced visibility of nursing contributions to outcomes. Reducing such waste may therefore require protecting clinical contact time, mobilising nursing expertise, preserving relational and individualised care, and strengthening the measurement and visibility of nursing-sensitive outcomes.

Introduction and Objective: Monitoring short-term changes in functional and neuromotor performance among older adults during a two-week hospital stay remains challenging in everyday geriatric practice. In this context, the present exploratory observational study aims at investigating the potential of the Clock Drawing Test, evaluated by means of quantitative geometric and kinematic parameters, as a method for capturing short-term fluctuations in visuomotor performance in routine multimodal inpatient care. The aim of the study is not to identify the isolated causal effects of single pharmacological or physical interventions, but to formulate hypotheses on the evolution of graphomotor trajectories within the framework of the usual clinical management. Methods: We conducted a prospective observational study involving 90 older adults hospitalized with chronic medical comorbidities and receiving multimodal inpatient care, including pharmacological treatments and physical rehabilitation techniques such as kinesiotherapy and TECAR therapy. Participants were classified into three diagnostic groups according to their cognitive status: no cognitive impairment (n = 40), mild cognitive impairment (n = 25), and dementia (n = 25). Results of the Clock Drawing Test performed at admission (T0) were compared with those performed at discharge (T14), focusing on contour integrity, numeral spacing, hand placement precision, and digital kinematic parameters. As the primary longitudinal outcome, paired T0 and T14 drawings were compared to evaluate short-term visuomotor changes. As a secondary exploratory analysis, baseline (T0) cognitive status classification was evaluated using Random Forest and Multilayer Perceptron models through participant-level 5-fold stratified cross-validation to determine how baseline neurocognitive and vascular profiles frame short-term graphomotor trajectories. Additionally, a binary (two-way) classification experiment (no cognitive impairment, n = 40, vs. cognitive impairment combining MCI and dementia, n = 50) was conducted, and the Structural Similarity Index (SSIM) was employed to objectively quantify whole-image morphological differences between CDT images obtained at admission (T0) and discharge (T14) using a standardized clock as ground truth. Results: Across the 90 complete pairs, significant Time × Regimen Cluster interactions were observed (p < 0.001). In Cluster 1 (multimodal physical and neurotrophic rehabilitation, n = 55), discharge evaluations showed significant improvements in contour closure gap (from 9.12 ± 2.45 mm to 1.78 ± 0.64 mm, p < 0.001), angular hand placement error (from 27.9° ± 6.8° to 4.1° ± 1.9°, p < 0.001), air-to-paper time ratio (from 1.84 ± 0.42 to 1.36 ± 0.31, p < 0.001), and Z-axis pressure stability (p < 0.001), whereas conceptual time-representation errors remained unchanged. Conversely, the small exploratory Cluster 2 subgroup that was treated with central nervous system depressants for acute inpatient insomnia or agitation showed a decline in graphomotor parameters (contour gap 2.15 ± 0.70 mm to 7.85 ± 2.30 mm, p = 0.016). This pattern could be a marker of either the pharmacodynamic sedation or the underlying acute neuropsychiatric conditions that warranted treatment. Conversely, Cluster 3 (standard medical maintenance, n = 27) remained stable (p > 0.20). For the secondary baseline classification task, the regularized Random Forest and Multilayer Perceptron models achieved promising internal cross-validation (out-of-fold) balanced accuracies of 86.00% and 88.13%, respectively. When reformulated as a two-way classification task (no impairment vs. MCI + dementia), out-of-fold overall accuracies increased to 92.22% (balanced accuracy 92.00%) for Random Forest and 94.44% (balanced accuracy 94.25%) for Multilayer Perceptron. Across 83 paired image sets, mean SSIM between T0 and T14 was 0.7494 ± 0.1016, while mean SSIM relative to the ground-truth clock changed from 0.7527 ± 0.0609 at T0 to 0.7352 ± 0.0687 at T14 (p < 0.001). Conclusions: Quantitative geometric and kinematic CDT parameters captured short-term changes in visuomotor execution over a 14-day hospitalization, while conceptual clock-drawing deficits remained associated with baseline diagnostic status in this exploratory observational cohort. Confounding by indication, practice effects and relief of pain or fatigue may also contribute to the observed trajectories in non-randomized multimodal care. Controlled trials and external multi-center validation cohorts are needed to confirm broader model generalizability and establish the independent effects of specific therapies.

Background/Objectives: Immune alterations in chronic heart failure (CHF) have been characterized mainly at the group level, leaving heterogeneity between patients undefined. We asked whether peripheral blood transcriptomes resolve distinct immune states within CHF, and how the same transcripts behave in tumors relevant to cardio-oncology. Methods: Features were selected from publicly available peripheral blood transcriptomes (CHF = 944, normal = 11) by multiple network analyses and machine learning algorithms, and consensus clustering was applied within the CHF cohort. Clusters were characterized by enrichment analyses and by estimated immune cell composition and immune-related functional signatures. The coordinates separating the clusters were fixed and applied to an independent CHF cohort of 197 patients with measured blood count differentials. Immunohistochemical and overall survival data from public tumor cohorts were examined. Results: Five weakly correlated transcripts (CASP6, CAPNS1, BAK1, CASP4 and BAD) separated the 944 patients with CHF into four clusters placed on two nearly independent coordinates, the dominant one being the balance between lymphoid and myeloid programs. Patients at opposite ends of that axis differed in almost every immune measure and in opposite directions, from a lymphoid-enriched, effector-engaged state to a myeloid-skewed, lymphoid-depleted state. Cluster 1, the largest at 39.5%, lay near the cohort average. Enriched terms were largely shared, so the separation was carried by immune cell composition rather than pathway level divergence. In the independent cohort, the coordinates kept the same relation to measured lymphocyte, neutrophil and monocyte counts. In exploratory tumor analyses, the five transcripts did not keep a single direction outside blood, and their associations with overall survival differed between tumor types. Conclusions: Peripheral blood transcriptomes place patients with CHF along a continuous lymphoid-to-myeloid axis, carried mainly by circulating immune cell composition, on which the four clusters mark positions rather than separate states and which holds in an independent cohort. Immune status in CHF is a property of the individual patient rather than of the population.