Screening for poverty and related social determinants to improve knowledge of and links to resources (SPARK): development and cognitive testing of a tool for primary care

BACKGROUND

Healthcare organizations are increasingly exploring ways to address the social determinants of health. Accurate data on social determinants is essential to identify opportunities for action to improve health outcomes, to identify patterns of inequity, and to help evaluate the impact of interventions. The objective of this study was to refine a standardized tool for the collection of social determinants data through cognitive testing.

METHODS

An initial set of questions on social determinants for use in healthcare settings was developed by a collaboration of hospitals and a local public health organization in Toronto, Canada during 2011-2012. Subsequent research on how patients interpreted the questions, and how they performed in primary care and other settings led to revisions. We administered these questions and conducted in-depth cognitive interviews with all the participants, who were from Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador. Cognitive interviewing was used, with participants invited to verbalize thoughts and feelings as they read the questions. Interview notes were grouped thematically, and high frequency themes were addressed.

RESULTS

Three hundred and seventy-five individuals responded to the study advertisements and 195 ultimately participated in the study. Although all interviews were conducted in English, participants were diverse. For many, the value of this information being collected in typical healthcare settings was unclear, and hence, we included descriptors for each question. In general, the questions were understood, but participants highlighted a number of ways the questions could be changed to be even clearer and more inclusive. For example, more response options were added to the question of sexual orientation and the "making ends meet" question was completely reworded in light of challenges to understand the informal phrasing cited by English as a Second Language (ESL) users of the tool.

CONCLUSION

In this work we have refined an initial set of 16 sociodemographic and social needs questions into a simple yet comprehensive 18-question tool. The changes were largely related to wording, rather than content. These questions require validation against accepted, standardized tools. Further work is required to enable community data governance, and to ensure implementation of the tool as well as the use of its data is successful in a range of organizations.

Patient-centered care in the emergency department: a systematic review and meta-ethnographic synthesis

BACKGROUND

Patient-centered care (PCC) is an emerging priority in many healthcare settings but lacks clarity in the emergency department (ED). It is of interest to know what PCC practices are most important to patients to better their experience. The objective of this study was to conduct a mixed-methods systematic review of PCC in the ED.

METHODS

We used stakeholder and patient engagement to consult with clinicians, subject-matter experts, patient partners, and community organizations to determine patient needs. We examined all articles in the ED context with PCC as the intervention. Two independent reviewers screened 3136 articles and 13 were included. A meta-ethnographic analysis was conducted to determine common themes of PCC.

RESULTS

Themes included emotional support, communication, education, involvement of patient/family in information sharing and decision making, comfort of environment, respect and trust, continuity, and transition of care. Challenges in the ED reflected a lack of PCC. Moreover, implementation of PCC had many benefits including higher patient satisfaction with their care. Though there were commonalities of PCC components, there was no consistently used definition for PCC in the ED.

CONCLUSION

The findings of this review support the evidence that PCC is of high value to the ED setting and should be standardized in practice.

Implementation of an ED surge management platform: a study protocol

BACKGROUND

Emergency departments (EDs) around the world are struggling with long wait times and overcrowding. To address these issues, a quality improvement program called SurgeCon was created to improve ED efficiency and patient satisfaction. This paper presents a framework for managing and evaluating the implementation of an ED surge management platform. Our framework builds on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to structure our approach and the Consolidated Framework for Implementation Research (CFIR) to guide our choice of outcome variables and scalability.

METHODS

Four hospital EDs will receive the SurgeCon quality improvement intervention. Using a stepped wedge cluster design, each ED will be randomized to one of four start dates. Data will be collected before, during, and after the implementation of the intervention. RE-AIM will be used to guide the assessment of SurgeCon, and guided by CFIR, we will measure ED key performance indicators (KPI), patient-reported outcomes, and implementation outcomes related to SurgeCon's scalability, adaptability, sustainability, and overall costs. Participants in this study consist of patients who visit any of the four selected EDs during the study period, providers/staff, and health system managers. A mixed-methods approach will be utilized to evaluate implementation outcomes.

DISCUSSION

This study will provide important insight into the implementation and evaluation techniques to enhance uptake and benefits associated with an ED surge-management platform. The proposed framework bridges research and practice by involving researchers, practitioners, and patients in the implementation and evaluation process, to produce an actionable framework that others can follow. We anticipate that the implementation approach would be generalizable to program implementations in other EDs.

TRIAL REGISTRATION

• Name of the registry: ClinicalTrials.gov • Trial registration number: NCT04789902 • Date of registration: 03/10/2021.

Directional coronary atherectomy in intermediate sized vessels: final results of the intermediate vessel atherectomy trial (IVAT)

Revascularization options for intermediate sized vessels (2.5-2.9 mm) have historically been limited. IVAT is a pilot study to assess the efficacy and safety of debulking intermediate sized vessels using directional coronary atherectomy (DCA). Between March 1996 and June 1997, 50 patients were enrolled at seven hospitals in the United States. Of those patients, 70% presented with unstable angina and 52% had single vessel disease. Of the lesions treated, 96% were de novo. Adjunctive PTCA after DCA was performed in 90% of cases at the discretion of the investigator to maximize luminal diameter. The GTO DCA device was used in 90% of cases. Procedural success (residual stenosis <50% without major complications) was 94%. Stents were placed in 12% of patients. The only complications were three non-Q wave MIs. Mean reference vessel diameter increased from 2.49 mm pre-procedure to 2.57 mm after DCA and 2.61 post-procedure; mean MLD increased from 0.76 mm to 2.03 mm to 2.31 mm; and mean stenosis decreased from 70% to 21% post DCA and to 11% post procedure. At six months follow-up, 18.0% of target lesions required revascularization. Total revascularization, including non-target vessels, was 32%. These results suggest that DCA has a high procedural success rate and a low target lesion revascularization rate in intermediate sized vessels.

Renal haemangioma in a dog

A three-and-a-half-year-old, spayed female, crossbred dog was presented with chronic haematuria. Diagnostic tests included abdominal ultrasonography, intravenous urography, cystoscopy and nephrectomy. Renal haemangioma was identified as the cause of the haematuria, which resolved postoperatively. A subcutaneous mass developed one month after the nephrectomy, which was diagnosed by biopsy as a cutaneous cavernous haemangioma. No other masses were reported one year later.

Hemolytic uremic syndrome in dogs

A disease syndrome similar to the hemolytic uremic syndrome of people is described in three dogs with acute renal failure. In each dog, hemorrhagic gastroenteritis preceded the onset of anuric acute renal failure. Evidence of microangiopathic hemolytic anemia (schizocytes, thrombocytopenia, and increased concentrations of fibrin split products) was present in the three dogs. Serum chemistry results showed increased concentrations of blood urea nitrogen, creatinine, and phosphorus. Ultrasound examination performed in one dog revealed increased echogenicity of the renal cortices. Treatment for anuric acute renal failure using a continuous dopamine and furosemide infusion established urine production in one of three dogs. Microscopic examination of tissue from the two dogs that underwent necropsy showed occlusion of the renal vasculature by fibrin thrombi consistent with microangiopathic arteriolar thrombosis. The pathophysiology and current knowledge of human hemolytic uremic syndrome is compared with hemolytic uremic syndrome in these dogs.

Globo-A--a new receptor specificity for attaching Escherichia coli

Uropathogenic Escherichia coli strains designated as ONAP, based on their O negative A positive agglutination of human P1 erythrocytes, were shown to prefer the globo-A glycolipid as a receptor structure. The dependence on both the A terminal and the globoseries chain was confirmed by agglutination of human AP1, but not Ap or OP1 erythrocytes and by binding to the globo-A glycolipid on TLC plates. Neither Gal alpha 1----4Gal beta nor the A trisaccharide GalNAc alpha 1----3(Fuc alpha 1----2)Gal beta alone functioned as receptors. The bacteria thus appeared to recognize an epitope resulting from the combination of the terminal and internal structures.

Measurement of gamma-interferon in culture supernatants of antigen-stimulated lymphocytes from patients with Schistosoma mansoni infections by a reverse passive haemagglutination assay

An assay for gamma-interferon (IFN gamma) in human lymphocyte culture supernatants, based on reverse passive haemagglutination (RPH) of red cells bearing a monoclonal anti-IFN gamma antibody, was developed and compared with a conventional virus inhibition assay. Test samples comprised supernatants of lymphocytes from patients with Schistosoma mansoni infections, cultured with or without a soluble worm antigen preparation. The two assays gave comparable results, the correlations for individual samples being good. The RPH assay was both specific and sensitive, allowing the detection of IFN gamma at 13 u/ml (1 ng/ml) or less. The advantages of the RPH assay were that it was quick, relatively inexpensive and suitable for testing large numbers of samples. In particular, between-experiment variation was very low, allowing the assay of different samples on different occasions.

Pathologic effects of ESWL on canine renal tissue

The introduction of extracorporeal shock wave lithotripsy (ESWL) has provided an avenue for dealing with many urinary stones noninvasively. The margin of safety for the kidney during shock wave administration is largely undefined. A pilot study was performed where six kidneys in five female mongrel dogs were shocked. Group A kidneys were given 1,776, 4,500, 6,000, or 8,000 shocks, respectively, at 18-24 kV. Group B kidneys received 1,600 and 8,000 shocks (18-24 kV). The number of shocks per electrode ranged from 500 to 4,538 and averaged 2,490. The dogs were sacrificed forty-eight to seventy-two hours (Group A) or twenty-eight to thirty-two days (Group B) post-treatment. Modest damage (hematoma and/or interstitial hemorrhage) was noted in all kidneys. Evidence of permanent change (fibrosis) was noted in both Group B kidneys. Complete necrosis of the kidney was not seen after administration of 8,000 shocks. These preliminary data indicate that lithotripsy can, in some circumstances, produce renal damage in the canine model.

Retrograde nephrostomy for stone removal: combined cystoscopic/percutaneous technique

The retrograde percutaneous nephrostomy, a new technique for access to the urinary tract for stone removal, involves cystoscopic placement of a 9 French catheter into a selected minor calix, through which a sheathed 20- or 21-gauge needle is then advanced to exit at the skin. The tract is then dilated over this needle. This technique has been used successfully in 38 patients with only three complications. The technique is more reliable and less time-consuming than the standard antegrade percutaneous approach, particularly in the nondilated pelvicaliceal system. However, to avoid damage to the liver, spleen, or pleural cavity, care must be taken to ensure that the needle does not exit in a cranial direction.

Hawkins-Hunter retrograde transcutaneous nephrostomy: a new technique

Retrograde nephrostomy, a new technique to aid in stone management, has been performed successfully in dogs. It has also been used without complication in a human patient to help remove a renal stone percutaneously under local anesthesia. The technique consists of placing a coaxial catheter over a guidewire under fluoroscopy into the exact calyx desired and advancing a long needle out to the skin to establish a transcutaneous tract. The advantages of the technique include increased control and precision of tract placement, efficient working angles for percutaneous stone removal, and the ability to perform the procedure under local anesthesia.

Physical chemistry of freeze-drying: measurement of sublimation rates for frozen aqueous solutions by a microbalance technique

The sublimation rate of frozen solutions was studied as a function of freezing rate, thickness of dried product (l), temperature, residual air pressure, and solute concentration. Data are presented for pure water, aqueous potassium chloride, aqueous povidone, and aqueous dobutamine hydrochloride-mannitol (System I). The resistance of the dried product to water vapor flow (Rp) was evaluated from the sublimation rate and the sample temperature. The primary experimental technique was based on freeze-drying a cylindrical microsample isothermally, with the sample suspended from one arm of a vacuum microbalance. Methodology to evaluate resistance data from vial freeze-drying experiments is also described. In separate experiments, samples in the form of a thin (15-microns) film were visually observed through a microscope during freeze-drying. Freeze-drying of most samples appeared to occur by water vapor escaping through open channels created by prior sublimation of ice. Contrary to the usual theoretical model, Rp is neither independent of temperature nor directly proportional to l. Rather, Rp decreases with increasing temperature and the l dependence is normally of the form Rp = (A0 + A1l)/(1 + A2l), where Ai (i = 0, 1, 2) are constants. In several cases, Rp is very large near l = 0, decreases sharply at l congruent to 0.1 cm, and obeys the above equation where l greater than 0.2 cm, a result suggesting an amorphous surface skin which cracks on desorption of water. The temperature dependence of Rp suggests that, as the sample temperature approaches the eutectic (or collapse) temperature, hydrodynamic surface flow of adsorbed water is an important flow mechanism.