Cardiovascular risk management among individuals with type 2 diabetes and severe mental illness: a cohort study

AIMS/HYPOTHESIS

The aim of this study was to compare cardiovascular risk management among people with type 2 diabetes according to severe mental illness (SMI) status.

METHODS

We used linked electronic data to perform a retrospective cohort study of adults diagnosed with type 2 diabetes in Scotland between 2004 and 2020, ascertaining their history of SMI from hospital admission records. We compared total cholesterol, systolic BP and HbA1c target level achievement 1 year after diabetes diagnosis, and receipt of a statin prescription at diagnosis and 1 year thereafter, by SMI status using logistic regression, adjusting for sociodemographic factors and clinical history.

RESULTS

We included 291,644 individuals with type 2 diabetes, of whom 1.0% had schizophrenia, 0.5% had bipolar disorder and 3.3% had major depression. People with SMI were less likely to achieve cholesterol targets, although this difference did not reach statistical significance for all disorders. However, people with SMI were more likely to achieve systolic BP targets compared to those without SMI, with effect estimates being largest for schizophrenia (men: adjusted OR 1.72; 95% CI 1.49, 1.98; women: OR 1.64; 95% CI 1.38, 1.96). HbA1c target achievement differed by SMI disorder and sex. Among people without previous CVD, statin prescribing was similar or better in those with vs those without SMI at diabetes diagnosis and 1 year later. In people with prior CVD, SMI was associated with lower odds of statin prescribing at diabetes diagnosis (schizophrenia: OR 0.54; 95% CI 0.43, 0.68, bipolar disorder: OR 0.75; 95% CI 0.56, 1.01, major depression: OR 0.92; 95% CI 0.83, 1.01), with this difference generally persisting 1 year later.

CONCLUSIONS/INTERPRETATION

We found disparities in cholesterol target achievement and statin prescribing by SMI status. This reinforces the importance of clinical review of statin prescribing for secondary prevention of CVD, particularly among people with SMI.

Type 1 diabetes-related distress: Current implications in care

Type 1 diabetes (T1D) is a complex chronic disease associated with major health and economic consequences, also involving important issues in the psychosocial sphere. In this regard, T1D-related distress, defined as the emotional burden of living with T1D, has emerged as a specific entity related to the disease. Diabetes distress (DD) is an overlooked but prevalent condition in people living with T1D, and has significant implications in both glycemic control and mental health in this population. Although overlapping symptoms may be found between DD and mental health disorders, specific approaches should be performed for the diagnosis of this problem. In recent years, different DD-targeted interventions have been postulated, including behavioral and psychosocial strategies. Moreover, new technologies in this field may be helpful to address DD in people living with T1D. In this article, we summarize the current knowledge on T1D-related distress, and we also discuss the current approaches and future perspectives in its management.

Severe postpartum hemorrhage and the risk of adverse maternal outcome: A comparative analysis of two population-based studies in France and the Netherlands

Objectives

Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery.

Methods

 Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion).

Findings

Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands.

Interpretation

Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.

A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study

BACKGROUND AND AIMS

There is significant potential to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the effect of implementing BENCHMARK best practices on the efficiency and safety of TAVI in 28 sites in 7 European countries.

METHODS

This was a study of patients with severe symptomatic aortic stenosis (AS) undergoing TAVI with balloon-expandable valves before and after implementation of BENCHMARK best practices. Principal objectives were to reduce hospital length of stay (LoS) and duration of intensive care stay. Secondary objective was to document patient safety.

RESULTS

Between January 2020 and March 2023, 897 patients were documented prior to and 1491 patients after the implementation of BENCHMARK practices. Patient characteristics were consistent with a known older TAVI population and only minor differences. Mean LoS was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001). Duration of intensive care was reduced from 1.8 to 1.3 days (median 1.1 vs. 0.9 days; P < .001). Adoption of peri-procedure best practices led to increased use of local anaesthesia (96.1% vs. 84.3%; P < .001) and decreased procedure (median 47 vs. 60 min; P < .001) and intervention times (85 vs. 95 min; P < .001). Thirty-day patient safety did not appear to be compromised with no differences in all-cause mortality (0.6% in both groups combined), stroke/transient ischaemic attack (1.4%), life-threatening bleeding (1.3%), stage 2/3 acute kidney injury (0.7%), and valve-related readmission (1.2%).

CONCLUSIONS

Broad implementation of BENCHMARK practices contributes to improving efficiency of TAVI pathway reducing LoS and costs without compromising patient safety.

Optimizing the Maastricht Work-Related Support intervention in clinical patient care: the value of integrating action research into intervention mapping

BACKGROUND

Healthcare professionals (HCPs) are increasingly recommended to play an important role in supporting people with chronic disease in work participation. An intervention for HCPs to provide work-related support to their patients in clinical care was developed with intervention mapping (Maastricht Work-Related Support; Maastricht WRS). Action research proposes 'combining research and practice', which allows us to incorporate experiences of HCPs while implementing and to realize intervention's full potential. Therefore, the aim of this study is to explore, by integrating action research into an intervention mapping approach, how experiences of HCPs with early implementation can be used to optimize the Maastricht WRS in clinical care.

METHODS

Semi-structured interviews were held with nine HCPs (response rate 82%), involved in care for people with inflammatory arthritis, knee problems or inflammatory bowel disease. Some of them were not yet trained in the Maastricht WRS while others had received the training and were providing the Maastricht WRS.

RESULTS

All participants regarded WRS an important part of clinical care. Untrained HCPs indicated a lack of knowledge and skills in providing the Maastricht WRS, and a need for tools. Trained HCPs were satisfied with the training and tools, but stressed that practical limitations hindered providing the Maastricht WRS. Action research showed that the intervention meets the needs of HCPs, but need some optimizations: (1) organizing 'intervision' for HCPs, (2) inform and activate patients to discuss work with their HCP, (3) update initial tools and (4) including patients' work status in the electronic patient system.

CONCLUSIONS

Action research integrated into intervention mapping proved to improve the Maastricht WRS intervention. By involving HCPs, the intervention could be optimized to provide to support people with chronic diseases in clinical care in healthy and sustainable work participation.

Perceptions and practices of people with a total laryngectomy during COVID-19 pandemic: A mixed methods analysis

PURPOSE

People with a total laryngectomy (PTL) confront safety threats related to altered airway anatomy and risk of adverse events is amplified during healthcare crises, as exemplified by COVID-19 pandemic. Understanding these challenges, how they are navigated by PTL, and what resources can be deployed to alleviate risk can improve interprofessional care by speech-language pathologists (SLPs), otolaryngologists, and other professionals.

MATERIALS AND METHODS

An online survey was disseminated to PTL in the United States during the COVID-19 pandemic, querying participants about safety concerns and sources of information accessed to address care. Descriptive statistics and Chi-square were used to analyze information sources consumed by tracheoesophageal, esophageal, and electrolaryngeal speakers. Content analysis was completed to identify themes and quantify responses by subtheme.

RESULTS

Among 173 respondent PTL, tracheoesophageal speakers preferentially sought otolaryngologist input, whereas esophageal and electrolaryngeal speakers more often chose SLPs (p < .01). Overall, tracheoesophageal speakers had more SLP or otolaryngologist contact. Many PTL reported stringent handwashing, neck cleaning, and hygienic risk mitigation strategies. Six themes emerged in content analysis involving risk of infection/transmission, heightened vigilance, changes to alaryngeal communication, modified tracheostoma coverage, diagnostic testing, and risk from comorbid conditions. Limited provider contact suggested pandemic barriers to healthcare access.

CONCLUSIONS

PTL have a range of laryngectomy-specific needs and concerns, and type of alaryngeal communication was associated with source of information sought. Collaborations among healthcare professionals need to be optimized to improve patient navigation and overall access to specialized care.

Experiences of treatment decision-making among older newly diagnosed adults with acute myeloid leukemia: a qualitative descriptive study

PURPOSE

Treatment decision-making for older adults with acute myeloid leukemia (AML) is complex and preference-sensitive. We sought to understand the patient experience of treatment decision-making to identify specific challenges in shared decision-making to improve clinical care and to inform the development of directed interventions.

METHODS

We conducted in-depth interviews with newly diagnosed older (≥ 60 years) adults with AML and their caregivers following a semi-structured interview guide at a public safety net academic hospital. Interviews were digitally recorded, and qualitative thematic analysis was employed to synthesize findings.

RESULTS

Eighteen in-depth interviews were conducted. Age ranged from 62 to 78 years. Patients received intermediate- (50%) or high-intensity (44%) chemotherapy or best supportive care only (6%). Six themes of patient experiences emerged from the analysis: patients (1) felt overwhelmed and in shock at diagnosis, (2) felt powerless to make decisions, (3) felt rushed and unprepared to make a treatment decision, (4) desired to follow oncologist recommendations for treatment, (5) balanced multiple competing factors during treatment decision-making, and (6) desired for ongoing engagement into their care planning. Patients reported many treatment outcomes that were important in treatment decision-making.

CONCLUSIONS

Older adults with newly diagnosed AML feel devastated and in shock at their diagnosis which appears to contribute to a feeling of being overwhelmed, unprepared, and rushed into treatment decisions. Because no one factor dominated treatment decision-making for all patients, the use of strategies to elicit individual patient preferences is critical to inform treatment decisions. Interventions are needed to reduce distress and increase a sense of participation in treatment decision-making.

The Cancer Survivorship Program at the Abramson Cancer Center of the University of Pennsylvania

The Cancer Survivorship Program was established at the University of Pennsylvania Cancer Center in 2001. The Cancer Center was renamed the Abramson Cancer Center of the University of Pennsylvania in 2002 and the survivorship program was henceforth known as the ACC Survivorship Program. The program was supported from 2001 to 2004 in part by a seed grant from the Lance Armstrong Foundation (LAF). The LIVESTRONG Survivorship Centers of Excellence Network was created by the LAF in 2005 and the ACC Survivorship Program joined the Network in 2007. The seven nationwide Cancer Centers that comprised the Network were supported by the LAF through 2015. A focus on clinical care, research, and education led the development of the ACC Survivorship Program. The program is currently led by an advanced practice provider (APP) and staffed by medical, surgical, and radiation oncology APPs and collaborating oncologists. This program provides care to adult survivors of pediatric cancers, as well as survivors of adult-onset cancers such as breast, genitourinary/prostate, lymphoma, head and neck, gastrointestinal, thoracic, sarcoma, and central nervous system. Research protocols for survivors of specific cancer diagnoses have been developed and have resulted in collaborative research, publications, and conference presentations. Sustaining the ACC Survivorship Program has been challenging despite strong endorsement of services by patients, families, and providers. Challenges include barriers such as cost restraints, changing cancer center priorities, and a reduced oncology workforce, issues experienced across the country that must be addressed in the years to come.

The Clinical Evolutions of Surveillance and Violence During Three Contemporary US Crises: Opioid Overdose, COVID-19, and Racial Reckoning

In 2020, three crises coalesced to transform the clinical care landscape of addiction medicine in the United States (US). The opioid overdose crisis (crisis #1), which had been contributing to excess US mortality for over two decades, worsened during the COVID-19 pandemic (crisis #2). The racial reckoning (crisis #3) spurred by the murder of George Floyd at the hands of police impacted clinical care, especially in safety net clinical settings where the majority of people targeted by police violence, and other forms of structural violence, receive healthcare to mend both physical and psychological wounds. Collectively, the three crises changed how providers and patients viewed their experiences of clinical surveillance and altered their relationships to the violence of US healthcare. Drawing from two different research studies conducted during the years preceding and during the COVID-19 pandemic (2017-2022) with low income, safety net patients at risk for opioid overdose and their care providers, I analyze the relationship between surveillance and violence in light of changes wrought by these three intersecting health and social crises. I suggest that shifting perceptions about surveillance and violence contributed to clinical care innovations that offer greater patient autonomy and transform critical components of addiction medicine care practice.

Experience and perceptions of healthcare providers on clinical management and care of near-miss infants: a qualitative content analysis

INTRODUCTION

Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia.

METHODS

Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis.

RESULTS

The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant.

CONCLUSION

Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

Development of a Novel Clinical Risk Score for COVID-19 Infections

OBJECTIVE

The ongoing emergence of novel severe acute respiratory syndrome coronavirus 2 strains such as the Omicron variant amplifies the need for precision in predicting severe COVID-19 outcomes. This study presents a machine learning model, tailored to the evolving COVID-19 landscape, emphasizing novel risk factors and refining the definition of severe outcomes to predict the risk of a patient experiencing severe disease more accurately.

METHODS

Utilizing electronic health records from the Healthjump database, this retrospective study examined over 1 million US COVID-19 diagnoses from March 2020 to September 2022. Our model predicts severe outcomes, including acute respiratory failure, intensive care unit admission, or ventilator use, circumventing biases associated with hospitalization, which exhibited ∼4× geographical variance of the new outcome.

RESULTS

The model exceeded similar predictors with an area under the curve of 0.83 without lab data to predict patient risk. It identifies new risk factors, including acute care history, health care encounters, and distinct medication use. An increase in severe outcomes, typically 2-3× higher than subsequent months, was observed at the onset of each new strain era, followed by a plateau phase, but the risk factors remain consistent across strain eras.

CONCLUSION

We offer an improved machine learning model and risk score for predicting severe outcomes during changing COVID-19 strain eras. By emphasizing a more clinically precise definition of severe outcomes, the study provides insights for resource allocation and intervention strategies, aiming to better patient outcomes and reduce health care strain. The necessity for regular model updates is highlighted to maintain relevance amidst the rapidly evolving COVID-19 epidemic.

Where do those data go? Reuse of screening results from clinical trials to estimate population prevalence of HBV infection in adults in Kilifi, Kenya

Chronic hepatitis B infection (CHB) is a significant problem worldwide with around 300 million people infected. Ambitious goals have been set towards its elimination as a public health threat by 2030. However, accurate seroprevalence estimates in many countries are lacking or fail to provide representative population estimates, particularly in the WHO African Region (AFRO). This means the full extent of HBV infection is not well described, leading to a lack of investment in diagnostics, treatment and disease prevention. Clinical trials in the WHO AFRO region have been increasing over time and many test for infectious diseases including hepatitis B virus (HBV) to determine baseline eligibility for participants, however these screening data are not reported. Here we review data from six clinical trials completed at the KEMRI-Wellcome Trust Research Programme between 2016 and 2023 that screened for HBV using hepatitis B surface antigen (HBsAg) as part of the trial exclusion criteria. 1727 people had HBsAg results available, of which 60 tested positive. We generated a crude period HBV prevalence estimate of 3.5% (95% CI 2.6-4.5%), and after standardisation for sex and age to account for the population structure of the Kilifi Health Demographics Surveillance System (KHDSS), the prevalence estimate increased to 5.0% (95% CI 3.4-6.6%). The underrepresentation of women in these trials was striking with 1263/1641 (77%) of participants being male. Alanine aminotransferase (ALT) was significantly higher in the HBsAg positive group but was not outside the normal range. We argue that routine collation and publishing of data from clinical trials could increase precision and geographical representation of global HBV prevalence estimates, enabling evidence-based provision of clinical care pathways and public health interventions to support progress towards global elimination targets. We do acknowledge when using clinical trials data for seroprevalence estimates, that local population structure data is necessary to allow standardisation of results, and the point of care tests used here are limited in sensitivity and specificity.

Family engagement in care for medical trainees and early career clinicians

Engaging family members in care improves person- and family-centered outcomes. Many healthcare professionals have limited awareness of the role and potential benefit of family engagement in care. This review describes the rationale for engaging families in care, and opportunities to engage family in various clinical care settings during training and early career practice.

[Mild cognitive impairment in geriatric practice: patient orientation, diagnostics, treatment and ethics]

Mild cognitive impairment (MCI) is a common problem in old people, which can be distressing for patients and their families. The main feature of MCI is a decrease in cognitive performance with activities of daily living still unimpaired. The identification of treatable risk factors, recognition of early cognitive changes and a timely differential diagnosis, comprehensive information and counselling are important tasks in geriatric medicine. The aim of this article is to present practical recommendations to support physicians working with geriatric patients in recognizing cognitive deficits at an early stage, provide high-quality care focusing on counselling, treatment, and comorbidity management and to maximize the potential of the available treatment options.

The use of deep learning in medical imaging to improve spine care: A scoping review of current literature and clinical applications

Background

Artificial intelligence is a revolutionary technology that promises to assist clinicians in improving patient care. In radiology, deep learning (DL) is widely used in clinical decision aids due to its ability to analyze complex patterns and images. It allows for rapid, enhanced data, and imaging analysis, from diagnosis to outcome prediction. The purpose of this study was to evaluate the current literature and clinical utilization of DL in spine imaging.

Methods

This study is a scoping review and utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to review the scientific literature from 2012 to 2021. A search in PubMed, Web of Science, Embased, and IEEE Xplore databases with syntax specific for DL and medical imaging in spine care applications was conducted to collect all original publications on the subject. Specific data was extracted from the available literature, including algorithm application, algorithms tested, database type and size, algorithm training method, and outcome of interest.

Results

A total of 365 studies (total sample of 232,394 patients) were included and grouped into 4 general applications: diagnostic tools, clinical decision support tools, automated clinical/instrumentation assessment, and clinical outcome prediction. Notable disparities exist in the selected algorithms and the training across multiple disparate databases. The most frequently used algorithms were U-Net and ResNet. A DL model was developed and validated in 92% of included studies, while a pre-existing DL model was investigated in 8%. Of all developed models, only 15% of them have been externally validated.

Conclusions

Based on this scoping review, DL in spine imaging is used in a broad range of clinical applications, particularly for diagnosing spinal conditions. There is a wide variety of DL algorithms, database characteristics, and training methods. Future studies should focus on external validation of existing models before bringing them into clinical use.

Provider adherence to clinical care recommendations for infants and children who died in seven low- and middle-income countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) network

Background

Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children.

Methods

We conducted a retrospective, descriptive study examining clinical data for children aged 1-59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016-June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration.

Findings

CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h.

Interpretation

Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence.

Funding

Bill & Melinda Gates Foundation.

A speech therapy for transgender women: an updated systematic review and meta-analysis

BACKGROUND

We systematically reviewed the literature and performed a meta-analysis on the effects of speech therapy and phonosurgery, for transgender women, in relation to the fundamental frequency gain of the voice, regarding the type of vocal sample collected, and we compared the effectiveness of the treatments. In addition, the study design, year, country, types of techniques used, total therapy time, and vocal assessment protocols were analyzed.

METHODS

We searched the PubMed, Lilacs, and SciELO databases for observational studies and clinical trials, published in English, Portuguese, or Spanish, between January 2010 and January 2023. The selection of studies was carried out according to Prisma 2020. The quality of selected studies was assessed using the Newcastle-Ottawa scale.

RESULTS

Of 493 studies, 31 were deemed potentially eligible and retrieved for full-text review and 16 were included in the systematic review and meta-analysis. Six studies performed speech therapy and ten studies phonosurgery. The speech therapy time did not influence the post-treatment gain in voice fundamental frequency (p = 0.6254). The type of sample collected significantly influenced the post-treatment voice frequency gain (p < 0.01). When the vocal sample was collected through vowel (p < 0.01) and reading (p < 0.01), the gain was significantly more heterogeneous between the different types of treatment. Phonosurgery is significantly more effective in terms of fundamental frequency gain compared to speech therapy alone, regardless of the type of sample collected (p < 0.01). The average gain of fundamental frequency after speech therapy, in the /a/ vowel sample, was 27 Hz, 39.05 Hz in reading, and 25.42 Hz in spontaneous speech. In phonosurgery, there was a gain of 71.68 Hz for the vowel /a/, 41.07 Hz in reading, and 39.09 Hz in spontaneous speech. The study with the highest gain (110 Hz) collected vowels, and the study with the lowest gain (15 Hz), spontaneous speech. The major of the included studies received a score between 4 and 8 on the Newcastle-Ottawa Scale.

CONCLUSION

The type of vocal sample collected influences the gain result of the fundamental frequency after treatment. Speech therapy and phonosurgery increased the fundamental frequency and improved female voice perception and vocal satisfaction. However, phonosurgery yielded a greater fundamental frequency gain in the different samples collected. The study protocol was registered at Prospero (CRD42017078446).

Motivations and expectations of parents seeking genetic testing for their children with ocular genetic disease

BACKGROUND

To date, almost 600 genes have been associated with ocular genetic diseases. As these discoveries are made, clinical genetic testing continues to grow and become a more common element in the diagnostic workup of children with blindness and reduced vision. However, few studies have explored the motivations of parents of pediatric patients for pursuing genetic testing or the topics they would like to discuss during their visit. This study explored these gaps in the existing knowledge of clinical care for children with vision loss.

MATERIALS AND METHODS

We distributed a REDCap survey to parents of pediatric patients in the Indiana University Ocular Genetics Clinic and through the Foundation Fighting Blindness MyRetinaTracker database to examine factors that motivate families to undergo genetic testing, topics they are interested in discussing, and satisfaction with their current care.

RESULTS

Parents were primarily motivated by the opportunity to learn about their child's prognosis, formal diagnosis, and possible treatment options. Parents were most interested in discussing prognosis, adaptations for vision loss, and testing logistics. Parents reported satisfaction with the care received; however, less than half were very satisfied with their understanding of prognosis and the support resources provided.

CONCLUSIONS

Parents seem to be generally satisfied by the care from their ocular genetics team. However, families' desires are not being fully met, especially with information about prognosis and support resources. As the field of ocular genetics continues to grow, it is important we improve these offerings and optimize care for this patient population.

Exploring staff perspectives on caring for isolated hospitalised patients during the COVID-19 pandemic: a qualitative study

BACKGROUND

Strict isolation of COVID-19 patients to prevent cross infection may inadvertently cause serious adverse outcomes including psychological harm, limitations to care, increased incidence of delirium, deconditioning and reduced quality of life. Previous research exploring the staff perspective of the effect of isolation on patients is limited. The aim of this study is to understand staff perceptions and interpretations of their experiences of the care and treatment of isolated patients and the impact of isolation on patients, families, and staff.

METHOD

This qualitative, exploratory study is set in a major metropolitan, quaternary hospital in Melbourne, Australia. Data was collected in focus groups with clinical and non-clinical staff and analysed using content analysis. The hospital ethics committee granted approval. Each participant gave informed verbal consent.

RESULTS

Participants included 58 nursing, medical, allied health, and non-clinical staff. Six main themes were identified: 1) Communication challenges during COVID-19; 2) Impact of isolation on family; 3) Challenges to patients' health and safety; 4) Impact on staff; 5) Challenging standards of care; 6) Contextual influences: policy, decision-makers and the environment.

CONCLUSION

Isolating patients and restricting visitors resulted in good pandemic management, but staff perceived it came at considerable cost to staff and consumers. Innovative communication technology may facilitate improved connection between all parties. Mental health support is needed for patients, families, and staff. Further research using a co-design model with input from patients, families and staff is recommended to determine appropriate interventions to improve care. Preventing the spread of infection is essential for good pandemic management, but the cost to consumers and staff must be mitigated. Preparation for future pandemics must consider workforce preparedness, adapted models of care and workflow.

Early Career Occupational Therapists' Experiences during the COVID-19 Pandemic

Occupational therapists entering the clinical workforce during the COVID-19 pandemic experienced levels of uncertainty and stress. This study's aim was to explore the clinical experiences and concerns of early-career occupational therapists entering the workforce during the COVID-19 pandemic (n = 27). We administered an open-ended online survey and analyzed the data using inductive thematic analysis. Resulting themes included: safety, exposure, and transmission; implementation and enforcement of safety protocols; quality of care; and impact of the pandemic on overall health highlighting the issues that need to be addressed to be more prepared for future practice in an evolving environment.

Current understanding of the chronic stress response to burn injury from human studies

There is a marked inflammatory and hypermetabolic response following a burn injury. The interlinked responses are more pronounced than for other forms of trauma and can persist for ≥3 years post-injury in burned patients. After a burn, patients have an increased risk of diseases of ageing including cancer, diabetes and cardiovascular disease, highlighting the need for effective long-term strategies to ameliorate the stress response post-burn. Current therapeutic strategies for post-burn recovery include removal of damaged tissue with surgical excision and wound repair, nutritional supplementation and rehabilitative exercise. These strategies aim to minimize the hypermetabolic and inflammatory responses, as well as reducing the loss of lean body mass. This review briefly summarises the inflammatory and hypermetabolic responses and provides an update on the current therapeutic strategies for burned patients. The review examines the persistent nutritional challenge of ensuring sufficient energy intake of each macronutrient to fuel the hypermetabolic and counteract the catabolic response of burn injury, whilst reducing periods of hyperglycaemia and hypertriglyceridemia. Patients require individualized treatment options tailored to unique systemic responses following a burn, facilitated by a precision medicine approach to improve clinical and physiological outcomes in burned patients. Thus, this review discusses the utility of metabolic flexibility assessment to aid clinical decision making and prescription relating to nutritional supplementation and rehabilitative exercise in the burned patient.

Competencies required for graduated physicians: the integration of Englander's common taxonomy in a validated scale for the assessment of competency acquiring in undergraduate medical education

BACKGROUND

Competency-based medical education has been emerging as a new educational model for learning. The development of medical education in Middle Eastern countries lacks basic literature in the area of medical education, particularly competency-based medical education (CBME).

AIM

Our objective is to validate a brief/rapid scale that informs us on the current perception of the acquiring of competencies of medical students and graduates from the Lebanese University, Lebanon.

METHODS

A survey containing the Englander's common taxonomy for medical competencies-a set of 57 items-was distributed to medical students and graduates from the Lebanese University. Three parameters were used for the validation of this scale: construct validity using the principal component analysis technique, internal reliability using Cronbach alpha, and convergent validity using Pearson correlation.

RESULTS

A total of 377 participants responded to the survey. Factor analysis, using Varimax rotation, showed appropriate loading of domains; loadings varied between 0.648 and 0.899. Construct validity showed for all competencies loaded appropriately in their respective domains; loadings ranged between 0.656 and 0.913. Cronbach alpha values were very good to excellent (0.868 to 0.932). Pearson correlation coefficients showed a good correlation with the total score and varied between 0.739 and 0.893 (p < 0.0001).

CONCLUSION

The Englander's common taxonomy scale is valid and reliable among Lebanese medical students and could be used for concise assessment of current and past medical education in faculties among Lebanese medical students. Using such scales can be used in assessing the improvement of medical education towards CBME.

PROMIS global health: potential utility as a screener to trigger construct-specific patient-reported outcome measures in clinical care

PURPOSE

Patient-reported outcome measures (PROMs), including global health and construct-specific measures, are collected across healthcare systems. Efforts should be made to reduce data collection burden and individualize survey administration to patient needs. Our study evaluated the ability of utilizing items on a global health measure to identify patients who may require additional screening.

METHODS

A cross-sectional study was conducted of patients who completed PROMIS Global Health (GH) as part of routine care, as well as additional construct-specific surveys, in a large healthcare system from 1/1/2016 to 12/31/2018. Receiver operating characteristic (ROC) analysis identified optimal thresholds for PROMIS GH items identifying clinically meaningful thresholds on construct-specific PROMs: PHQ-9 score ≥10, Neuro-QoL Cognitive Function, PROMIS Physical Function, and Satisfaction with Social Roles and Activities T-score ≤40, PROMIS Anxiety, Fatigue, Sleep Disturbance, and Pain Interference T-score ≥60.

RESULTS

There were 206,685 patients who completed PROMIS GH and additional construct-specific surveys. Scores ≤3 on PROMIS GH item 10 (emotional problems) had 90.0% sensitivity (area under the curve (AUC) = 0.821) for identifying patients with moderate-severe depressive symptoms on PHQ-9. Similarly high sensitivities and AUCs were demonstrated for PROMIS GH items assessing mental and physical health, fatigue, and pain to identify poor scores on their corresponding construct-specific PROMs.

CONCLUSIONS

Our study provides preliminary support for the ability of utilizing PROMIS GH items as screening tools to identify patients with poor scores on additional construct-specific PROMs. Through directing construct-specific PROMs to patients for whom they are most applicable, survey burden could be reduced for many patients, allowing a more efficient and targeted use of PROMs in healthcare decision-making.

Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle

This paper summarizes a novel quality improvement initiative by a Child and Adolescent Psychiatry outpatient service to enhance the quality of clinical documentation through effective use of a standardized template. It involved carrying out an initial audit, implementation of an action plan to rectify the identified shortcomings, and completion of the audit cycle by repeating the process a year later. A significant improvement was noted across all the measurable standards. We have demonstrated that standardization of clinical documentation, reviewing and addressing factors affecting the compliance rates, and providing necessary training to doctors can all enhance the quality of clinical documentation.

An Initiative "that you do for one person": Identifying Barriers and Facilitators to Implementing an Immediate Postpartum LARC Initiative in Florida Hospitals

INTRODUCTION

In the United States (U.S.), perinatal quality improvement collaboratives have pursued implementing immediate postpartum long-acting reversible contraception (LARC) initiatives to increase people's access to contraception and support their fertility desires. This process evaluation aimed to identify barriers and facilitators to implementing an immediate postpartum LARC initiative in Florida.

METHODS

Data collection included in-depth qualitative assessments (i.e., interviews, small focus group discussions) with hospitals in pre- and early stages of the implementation process. Snowball sampling was used to recruit participants. Interviews were conducted in-person or via Zoom or phone and were audio-recorded and transcribed verbatim. Four of the five domains within the Consolidated Framework for Implementation Research (e.g., process, intervention characteristics, inner and outer settings) informed the study design and data collection/analysis.

RESULTS

Fourteen staff of diverse job roles from five hospitals participated. Factors that facilitated implementation were the strength of the evidence, relative advantage, internal and external networks, and engaging staff. Barriers to implementation included billing and reimbursement and needing significant support from external networks to progress through implementation phases.

DISCUSSION

Findings suggest that depending on the task or phase, multiple factors work in tandem to serve as implementation barriers and facilitators. Additionally, evaluating hospitals' progress at the pre- and early implementation phases was critical for quickly finding solutions and benefited other hospitals in different stages. As this initiative requires substantial support, health systems should create and sustain a culture of excellence and efficiency to facilitate implementing initiatives that improve care quality.

Clinicians' Use of Quantitative Information while Assessing the Rate of Functional Progression in Glaucoma

PURPOSE

Clinicians use both global and point-wise information from visual fields to assess the rate of glaucomatous functional progression. We asked which objective, quantitative measures best correlated with subjective assessment by glaucoma experts. In particular, we aimed to determine how much that judgment was based on localized rates of change vs. on global indices reported by the perimeter.

DESIGN

Prospective cohort study.

PARTICIPANTS

Eleven academic, expert glaucoma specialists independently scored the rate of functional progression, from 1 (improvement) to 7 (very rapid progression), for a series of 5 biannual clinical printouts from 100 glaucoma or glaucoma suspect eyes of 51 participants, 20 of which were scored twice to assess repeatability.

METHODS

Regression models were used to predict the average of the 11 clinicians' scores based on objective rates of change of mean deviation (MD), visual field index (VFI), pattern standard deviation (PSD), the Nth fastest progressing location, and the Nth fastest progressing of 10 anatomically defined clusters of locations after weighting by eccentricity.

MAIN OUTCOME MEASURES

Correlation between the objective rates of change and the average of the 11 clinicians' scores.

RESULTS

The average MD of the study eyes was -2.4 dB (range, -16.8 to +2.8 dB). The mean clinician score was highly repeatable, with an intraclass correlation coefficient of 0.95. It correlated better with the rate of change of VFI (pseudo-R2 = 0.73, 95% confidence interval [CI, 0.60-0.83]) than with MD (pseudo-R2 = 0.63, 95% CI [0.45-0.76]) or PSD (pseudo-R2 = 0.41, 95% CI [0.26-0.55]). Using point-wise information, the highest correlations were found with the fifth-fastest progressing location (pseudo-R2 = 0.71, 95% CI [0.56-0.80]) and the fastest-progressing cluster after eccentricity weighting (pseudo-R2 = 0.61, 95% CI [0.48-0.72]). Among 25 eyes with an average VFI of > 99%, the highest observed pseudo-R2 value was 0.34 (95% CI [0.16-0.61]) for PSD.

CONCLUSIONS

Expert academic glaucoma specialists' assessment of the rate of change correlated best with VFI rates, except in eyes with a VFI near the ceiling of 100%. Sensitivities averaged within clusters of locations have been shown to detect change sooner, but the experts' opinions correlated more closely with global VFI. This could be because it is currently the only index for which the perimeter automatically provides a quantitative estimate of the rate of functional progression.

Clinicians' Use of Quantitative Information When Assessing the Rate of Structural Progression in Glaucoma

PURPOSE

OCT scans contain large amounts of information, but clinicians often rely on reported layer thicknesses when assessing the rate of glaucomatous progression. We sought to determine which of these quantifications most closely relate to the subjective assessment of glaucoma experts who had all the diagnostic information available.

DESIGN

Prospective cohort study.

PARTICIPANTS

Eleven glaucoma specialists independently scored the rate of structural progression from a series of 5 biannual clinical OCT printouts.

METHODS

A total of 100 glaucoma or glaucoma suspect eyes of 51 participants were included; 20 were scored twice to assess repeatability. Scores ranged from 1 (improvement) to 7 (very rapid progression). Generalized estimating equation linear models were used to predict the mean clinician score from the rates of change of retinal nerve fiber layer thickness (RNFLT) or minimum rim width (MRW) globally or in the most rapidly thinning of the 6 sectors.

MAIN OUTCOME MEASURES

The correlation between the objective rates of change and the average of the 11 clinicians' scores.

RESULTS

Average RNFLT within the series of study eyes was 79.3 μm (range, 41.4-126.6). Some 95% of individual clinician scores varied by ≤ 1 point when repeated. The mean clinician score was more strongly correlated with the rate of change of RNFLT in the most rapidly changing sector in %/year (pseudo-R2 = 0.657) than the rate of global RNFLT (0.372). The rate of MRW in the most rapidly changing sector had pseudo-R2 = 0.149.

CONCLUSIONS

The rate of change of RNFLT in the most rapidly changing sector predicted experts' assessment of the rate of structural progression better than global rates or MRW. Sectoral rates may be a useful addition to current clinical printouts.

Clinical management of COVID-19 in hospitals and the community: A snapshot from a medical insurance database in South Africa

BACKGROUND

Little is known about the clinical care, use of medicines, and risk factors associated with mortality among the population with private health insurance with COVID-19 in South Africa.

METHODS

This was a retrospective cross-sectional study using claims data of patients with confirmed COVID-19. Sociodemographics, comorbidities, severity, concurrent/progressive comorbidity, drug treatment, and outcomes were extracted from administrative data. Univariate and multivariate logistic regression models were used to explore the risk factors associated with in-hospital death.

RESULTS

This study included 154,519 patients with COVID-19; only 24% were categorized as severe because they received in-hospital care. Antibiotic (42.8%) and steroid (30%) use was high in this population. After adjusting for known comorbidities, concurrent/progressive diagnosis of the following conditions were associated with higher in-hospital death odds: acute respiratory distress syndrome (aOR = 1.55; 95% CI = 1.44-1.68), septic shock (aOR = 1.55; 95% CI = 2.00-4.12), pneumonia (aOR = 1.35; 95% CI = 1.24-1.47), acute renal failure (aOR = 2.30; 95% CI = 2.09-2.5), and stroke (aOR = 2.09; 95% CI = 1.75-2.49). The use of antivirals (aOR = 0.47; 95% CI= 0.40-0.54), and/or steroids (aOR = 0.46; 95% CI = 0.43-0.50) were associated with decreased death odds. The use of antibiotics in-hospital was not associated with increased survival (aOR = 0.97; 95% CI = 0.91-1.04).

CONCLUSIONS

Comorbidities remain significant risk factors for death mediated by organ failure. The use of antibiotics did not change the odds of death, suggesting inappropriate use.

Incorporation of Telepsychiatry for Patients with Developmental Disorders into Routine Clinical Practice-A Survey of Specialty Clinics Adapting to Telepsychiatry During the COVID-19 Pandemic

In 2020, a nationwide shift to telepsychiatry occurred in the wake of the Coronavirus Disease 2019 (COVID-19) pandemic and lockdowns. To assess the rates of telepsychiatry appointment attendance pre- and post-lockdown, we conducted a national, multi-site survey of appointments in 2020 compared to a similar time period in 2019, at outpatient child psychiatry clinics that specialize in the treatment of patients with Autism Spectrum Disorder (ASD) and/or Developmental Disabilities (DD). ASD/DD clinics rapidly shifted to telepsychiatry, returning to pre-pandemic appointment numbers and completion rates within months. We advocate for the continued funding of this care model, discuss the substantial benefits physicians, patients and families have found in using telepsychiatry, and suggest ways to improve future access for ASD/DD telepsychiatry.

Quality of care metrics for patients with inborn errors of metabolism

Despite recent calls to action and a heavy emphasis on timeliness of care in guidelines for common inborn errors of metabolism, there is a dearth of specific measurable quality metrics for these conditions and little to no electronic decision support for their management. We have developed a novel set of process-oriented metrics based on the aforementioned guidelines that can be calculated from data already contained in most major EHRs, which we believe are responsive to the needs of the metabolism community.

Implementing patient-reported outcomes in routine clinical care for diverse and underrepresented patients in the United States

BACKGROUND

Patient-reported outcomes (PROs) are used increasingly in routine clinical care and inform policies, reimbursements, and quality improvement. Less is known regarding PRO implementation in routine clinical care for diverse and underrepresented patient populations.

OBJECTIVE

This review aims to identify studies of PRO implementation in diverse and underrepresented patient populations, elucidate representation of clinical specialties, assess implementation outcomes, and synthesize patient needs, concerns, and preferences.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched September 2021 for studies aiming to study PRO implementation in diverse and underrepresented patient populations within the United States. Studies were screened and data extracted by three independent reviewers. Implementation outcomes were assessed according to Proctor et al. taxonomy. A descriptive analysis of data was conducted.

RESULTS

The search yielded 8,687 records, and 28 studies met inclusion criteria. The majority were observational cohort studies (n = 21, 75%) and conducted in primary care (n = 10, 36%). Most studies included majority female (n = 19, 68%) and non-White populations (n = 15, 54%), while fewer reported socioeconomic (n = 11, 39%) or insurance status (n = 9, 32.1%). Most studies assessed implementation outcomes of feasibility (n = 27, 96%) and acceptability (n = 19, 68%); costs (n = 3, 11%), penetration (n = 1, 4%), and sustainability (n = 1, 4%) were infrequently assessed.

CONCLUSION

PRO implementation in routine clinical care for diverse and underrepresented patient populations is generally feasible and acceptable. Research is lacking in key clinical specialties. Further work is needed to understand how health disparities drive PRO implementation outcomes.

Assessing Patient-Reported Outcomes in Pediatric Rheumatic Diseases: Considerations and Future Directions

For children with pediatric rheumatic diseases (PRDs), the inclusion of patient-reported outcomes (PROs) is critical to inform decision making in health care delivery and research settings. PROs are direct reports from a child on their health status, without interpretation by anyone else. PROs improve understanding of the patient experience, allow clinicians to provide patient-centered care, and add value to clinical trials. When PROs cannot be collected directly from the patient, caregiver-proxy reports can provide important information on the child's more observable symptoms and functioning. In this article, we describe the current use of PROs in specific PRDs, align current research with best practice recommendations for both clinical care and research settings, highlight exciting new developments, and identify areas for future research.

Personalized outcomes for hip and knee replacement: the patients point of view

BACKGROUND

Patient reported outcome measures (PROMs) are increasingly being incorporated into clinical and surgical care for assessing outcomes. This study examined outcomes important to patients in their decision to have hip or knee replacement surgery, their perspectives on PROMs and shared decision-making, and factors they considered important for postoperative care.

METHODS

A cross-sectional study employing survey methods with a stratified random sample of adult orthopedic patients who were scheduled for or recently had hip or knee replacement surgery.

RESULTS

In a representative sample of 226 respondents, patients identified personalized outcomes important to them that they wanted from their surgery including the ability to walk without pain/discomfort, pain relief, and returning to an active lifestyle. They preferred a personalized outcome (54%) that they identified, compared to a PROM score, for tracking progress in their care and thought it important that their surgeon know their personal outcomes (63%). Patients also wanted to engage in shared decision-making (79%) about their post-surgical care and identified personal factors important to their aftercare, such as living alone and caring for pets.

CONCLUSIONS

Patients identified unique personalized outcomes they desired from their care and that they wanted their orthopedic surgeons to know about. Asking patients to identify their personalized outcomes could add value for both patients and surgeons in clinical care, facilitating more robust patient involvement in shared decision-making.

Characterizing the Impact of COVID-19 on Pre-Exposure Prophylaxis (PrEP) Care

COVID-19 is a public health crisis that has fundamentally altered health care provision. The purpose of this study was to examine the impact of COVID-19 on pre-exposure prophylaxis (PrEP) care. We reviewed all patient records for those who presented for PrEP care at a PrEP program in Providence, Rhode Island from September 1st, 2019 to May 29th, 2020. The number of PrEP encounters decreased but was not significantly different over time (ps > .05). Patients were still able to access PrEP clinical services during the COVID-19 pandemic. Implementing flexible and timely PrEP delivery approaches in this setting likely minimized the disruption of PrEP care during COVID-19.

Aging and Women's Health: An Update from the National Institute on Aging

Older women outnumber older men in the United States and may experience a range of physical, cognitive, social, and emotional challenges. The "Geriatric 5 Ms"-Multicomplexity, Mind, Mobility, Medications, and What Matters Most-provide a useful framework for understanding and addressing the health and wellness needs of older women in the clinic. The National Institute on Aging, a component of the US National Institutes of Health, supports a vibrant program of aging research with many immediately implementable findings and useful resources for the busy clinician.

Normalising comparative effectiveness trials as clinical practice

There is a lack of high-quality evidence underpinning many contemporary clinical practice guidelines embedded in the healthcare systems, leading to treatment uncertainty and practice variation in most medical disciplines. Comparative effectiveness trials (CETs) represent a diverse range of research that focuses on optimising health outcomes by comparing currently approved interventions to generate high-quality evidence to inform decision makers. Yet, despite their ability to produce real-world evidence that addresses the key priorities of patients and health systems, many implementation challenges exist within the healthcare environment.

This manuscript aims to highlight common barriers to conducting CETs and describes potential solutions to normalise their conduct as part of a learning healthcare system.

A study of Indiana University Health's spirit of inquiry and innovation during COVID

Background

COVID-19 has required nursing innovations to meet patient care needs not previously encountered.

Purpose

The purpose of this study was to describe nursing innovations conceived, implemented, and desired during the first COVID-19 surge.

Methods

The investigators invited registered nurses employed across 16 Midwest hospitals (6,207) to complete the survey. Respondents provided demographics and written descriptions of innovations they conceived, witnessed, and desired. Investigators analyzed text responses using standard content analytic procedures and summarized quantitative demographics using percentages.

Findings

Nurses reported seven types of innovations that would (a) improve personal protective equipment (PPE), (b) limit the need to repeatedly don and doff PPE, (c) ensure safer practice, (d) conserve and access supplies, (e) provide patient and family education and support, (f) make team member communication more efficient, and (g) improve peer support.

Discussion

Nurses are in a unique position to generate innovative solutions to meet patient care needs under adverse and rapidly changing situations.

Management of CLN1 Disease: International Clinical Consensus

BACKGROUND

CLN1 disease (neuronal ceroid lipofuscinosis type 1) is a rare, genetic, neurodegenerative lysosomal storage disorder caused by palmitoyl-protein thioesterase 1 (PPT1) enzyme deficiency. Clinical features include developmental delay, psychomotor regression, seizures, ataxia, movement disorders, visual impairment, and early death. In general, the later the age at symptom onset, the more protracted the disease course. We sought to evaluate current evidence and to develop expert practice consensus to support clinicians who have not previously encountered patients with this rare disease.

METHODS

We searched the literature for guidelines and evidence to support clinical practice recommendations. We surveyed CLN1 disease experts and caregivers regarding their experiences and recommendations, and a meeting of experts was conducted to ascertain points of consensus and clinical practice differences.

RESULTS

We found a limited evidence base for treatment and no clinical management guidelines specific to CLN1 disease. Fifteen CLN1 disease experts and 39 caregivers responded to the surveys, and 14 experts met to develop consensus-based recommendations. The resulting management recommendations are uniquely informed by family perspectives, due to the inclusion of caregiver and advocate perspectives. A family-centered approach is supported, and individualized, multidisciplinary care is emphasized in the recommendations. Ascertainment of the specific CLN1 disease phenotype (infantile-, late infantile-, juvenile-, or adult-onset) is of key importance in informing the anticipated clinical course, prognosis, and care needs. Goals and strategies should be periodically reevaluated and adapted to patients' current needs, with a primary aim of optimizing patient and family quality of life.

Patient-Reported Outcomes in Patients with Cardiomyopathy

PURPOSE OF REVIEW

As medicine strives to become more patient-centered, patient-reported outcomes (PROs) are often used to describe patients' symptoms, function, and quality of life. This review describes the key concepts of PROs specific to heart failure in clinical trials and their potential role in clinical practice.

RECENT FINDINGS

As the Food and Drug Administration has increasingly emphasized how it values PROs as clinical outcome assessments, including its recent qualification of the Kansas City Cardiomyopathy Questionnaire (KCCQ), clinical trials have increasingly used them to evaluate novel therapies. This has been enhanced by an increasing understanding of how to interpret KCCQ scores. Its use in clinical practice, including the importance of providers sharing results with their patients, is just emerging. PROs provide unique insights into the benefits of treatment from patients' perspectives and while their role in clinical care is just beginning, they offer an important opportunity to improve the patient-centeredness of care.

Perceived Parameters of Christian Pharmacy Students' Faith-Sharing in Clinical Settings

Our interdisciplinary team (which included professionals from nursing, pharmacy, allied health, and psychology) conducted in-depth, semi-structured interviews with pharmacy students (n = 14) who were presently in a clinical rotation. When conducting the phenomenological, qualitative research study, we explored how students framed their respective experiences of incorporating spirituality into their clinical work. Three themes emerged from the interviews: (1) The students reportedly viewed their main role as being more of a support person than an evangelist, (2) They framed their influence from the perspective of so-called faith flags, and (3) They perceived more opportunities for influence with their coworkers than with patients. We discuss the findings in light of published findings and also in terms of how health care workers frame the concept of "ministry."

Upstream With A Small Paddle: How ACOs Are Working Against The Current To Meet Patients' Social Needs

Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients' social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently "flying blind," lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs' difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.

Best-practice clinical management of flares in people with osteoarthritis: A scoping review of behavioral, lifestyle and adjunctive treatments

INTRODUCTION

Transient episodes of increased pain, stiffness or swelling are common in people with osteoarthritis (OA). Yet, evidence-based management strategies for lessening the impact of OA flares are rarely covered in clinical guidelines and have been identified as a gap by clinicians delivering OA care. We aimed to identify evidence on behavioral, lifestyle or other adjunctive flare management strategies that could be used by clinicians or consumers.

MATERIALS AND METHODS

A literature search between 1990-2020 was performed in three databases using a scoping methodology. We included qualitative or quantitative studies, and reviews that examined OA flare management, or that reported OA flare outcomes at timepoints ≤2 weeks post-intervention. Outcomes included any physical or psychological OA outcome treatable with a therapeutic intervention.

RESULTS

We included 9 studies, all of which examined the relationship between therapeutic exercise/ physical activity and OA flares. All studies reported pain outcomes at the knee. Two also included the hip. Only two studies examined specific management strategies for OA flares. Both favorably reported the benefits of undertaking an exercise program modified accordingly during an episode, but the quality of the evidence was low.

DISCUSSION

This scoping review highlights the paucity of evidence available on non-pharmacological treatments of OA flare management that could influence clinical practice. At present, there is no robust evidence to support or reject any specific therapies for OA flare management in clinical practice. Future work is needed, particularly around outcomes beyond pain, trajectories of symptom improvement, and for joints other than the knee.

Enhanced recovery pathway in adult patients undergoing thoracolumbar deformity surgery

BACKGROUND CONTEXT

Enhanced recovery (ERAS) pathways can help hospitals maximize the incentives of bundled payment models while maintaining high-quality patient care. A key component of an enhanced recovery pathway is the ability to predictably reduce inpatient length of stay, as this is a critical component of the cost equation.

PURPOSE

To determine the efficacy of an enhanced recovery pathway on reducing length of stay after thoracolumbar adult deformity surgery.

STUDY DESIGN

Single surgeon retrospective review of prospectively-collected data.

PATIENT SAMPLE

Forty adult deformity patients who underwent ≥5 levels of fusion to the pelvis (two to L5) with a single surgeon before and after implementation of an ERAS pathway.

METHODS

The pathway involved participation by anesthesiology, hospital medicine, and physical therapy, and was designed to achieve goals previously associated with decreased LOS (eg, EBL<1200 mL, procedure time <4.5 hours, avoidance of ICU postoperatively, and mobilization POD0-1). Patients were propensity-score matched 1:1 to a historical cohort (enhanced recovery [ER] and historical [H] cohorts), based on demographics, medical comorbidities, radiographic alignment parameters, and surgical factors. Outcomes were compared to determine the effect of the enhanced recovery pathway. Primary outcomes included LOS and 90-day complications and readmissions.

RESULTS

After matching, gender, BMI, ASA class, preoperative opioid dependence, day of surgery, sagittal alignment parameters, rate of revision surgery, three-column osteotomies, and interbody fusions were comparable between the cohorts (p>.05). In the ER cohort, there was reduced EBL (920±640 vs. 1437±555, p=.004) and no ER patient went to the ICU immediately following surgery, compared with 30% of H patients (p=.022). The ER cohort also had a greater number of patients ambulating by POD1 compared to the H cohort (100% vs. 55%, p=.010). ER patients had a shorter LOS (4.5±1.3 vs. 7.3±4.4 days, p=.010). A 90-day readmission and complications were comparable between the cohorts (p>.05).

CONCLUSIONS

The creation of an ERAS pathway for patients undergoing thoracolumbar adult deformity surgery reduced length of stay without negatively affecting short-term morbidity and complications. Given the specificity of this pathway to a single surgeon and hospital, the resources and staffing changes that were instrumental in creating the pathway may not be generalizable to other centers.

Receipt Of Home-Based Medical Care Among Older Beneficiaries Enrolled In Fee-For-Service Medicare

Millions of older Americans are homebound and may benefit from home-based medical care. We characterized the receipt of this care among community-dwelling, fee-for-service Medicare beneficiaries ages sixty-five and older surveyed in the National Health and Aging Trends Study between 2011 and 2017. Five percent of those surveyed received any home-based medical care between 2011 and 2017 (mean follow-up time per person was 3.4 years), and 75 percent of home-based medical care recipients were homebound. Only 11 percent of the total homebound population (approximately 4.4 million fee-for-service Medicare beneficiaries in 2017) received any home-based medical care between 2011 and 2017. Receipt of home-based medical care was more common among homebound beneficiaries living in metropolitan areas and assisted living facilities, which suggests that geographic factors create operational efficiencies for home-based medical care practices that may improve their financial sustainability within the fee-for-service reimbursement setting. The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care.

Evaluating implementation and pragmatism of cancer-specific exercise programs: a scoping review

PURPOSE

Studies in exercise oncology are increasingly evaluating the implementation of cancer-specific exercise programming in real-world settings. Evaluating current implementation efforts and identifying current research gaps may inform future implementation. This scoping review explores studies implementing cancer-specific exercise programs to determine their pragmatic characteristics and evaluate potential for translation into practice.

METHODS

A systematic literature search was conducted using five databases (up to July 2020) to identify implementation studies that used qualitative or quantitative methods. Program pragmatism was evaluated using the PRECIS/RE-AIM tool.

RESULTS

Fourteen articles were included for review. While programs were moderately pragmatic (average: 3.4; range: 2.8-4.2), variability was observed between scoring domains. Programs scored higher (more pragmatic) in domains typical for effectiveness studies, including participant eligibility, follow-up intensity, primary trial outcome, and analysis of primary outcome. In contrast, programs scored lower (less pragmatic) in domains aligned with implementation science, including intervention flexibility, adoption, implementation, and maintenance. Limited information was reported regarding program fidelity, adaptations, and maintenance/sustainability.

CONCLUSION

Researchers should consider the pragmatism of interventions, the nuances of program adoption and implementation at the setting level, and the transition and integration of programming into the healthcare system. Future studies may benefit from the inclusion of decision-makers and implementation experts and shifting focus towards flexible programming. PRECIS/RE-AIM may facilitate the evaluation of programs throughout the study design and implementation process.

IMPLICATIONS FOR CANCER SURVIVORS

The implementation of pragmatic exercise programs that are both scalable and sustainable is needed so that cancer survivors can experience exercise-related benefits beyond research settings.

Morbid Obesity Increases 30-Day Readmission and Morbidity in Clostridiodes difficile Infection

BACKGROUND

Readmission for patients hospitalized with Clostridioides difficile infections (CDIs) carries high morbidity, mortality, and burden on healthcare resources. This study aims to determine if morbid obesity is risk factor for 30-day readmission in patients hospitalized with CDI.

METHODS

This retrospective cohort study used the 2014 National Readmission Database. Included patients had a principal diagnosis of CDI and excluded if younger than 18 years of age or admitted during the month of December. Readmissions to any hospital for non-trauma diagnoses within 30 days of the index admission were included. The primary outcome was 30-day all cause readmission. Secondary outcomes were (1) in-hospital mortality; (2) morbidity, initiation of dialysis, or total parenteral nutrition; and (3) resource utilization during index admissions.

RESULTS

A total of 91,265 subjects were included in this study, 4388 of whom were morbidly obese. Morbid obesity was associated with significantly higher odds of readmission and was associated with higher adjusted mean total hospitalization charges and costs, higher odds of PMV, and acute renal failure requiring dialysis in individuals that develop CDI.

CONCLUSIONS

Morbid obesity is an independent risk factor for 30-day readmission in patients hospitalized for CDI. Morbidly obese patients admitted for CDI experienced higher morbidity and increased resource utilization.

The impact of the COVID-19 pandemic on neurofibromatosis clinical care and research

Purpose

The coronavirus disease 2019 (COVID-19) pandemic has had unprecedented impact on the provision of medical care for genetic disorders. The purpose of this study was to assess the effects of the pandemic on neurofibromatosis (NF) care and research.

Methods

Sixty-three United States NF clinics were surveyed to identify the impact of the pandemic on clinician role, patient volume, continuity of guideline-driven surveillance, research protocols, and use of (and satisfaction with) telehealth for the delivery of NF care.

Results

Fifty-two clinic directors or their representatives completed the survey (83% response rate). About 2/3 of the clinics reported a greater than 50% decrease in the number of available patient appointments, and modified clinical surveillance and research protocols. Fifty-one clinics (98%) newly instituted telehealth during the pandemic. Barriers to telehealth prior to the pandemic were insurance reimbursement concerns and lack of infrastructure. Since telehealth was initiated, high provider satisfaction was reported with ease of use. The most common area of concern was related to inability to perform a physical examination.

Conclusion

Results show marked impacts on NF care and research since the beginning of the pandemic, with potential long-term changes related to the introduction (or adoption) of telehealth for clinical care.

Delivery of paediatric rheumatology care: a survey of current clinical practice in Southeast Asia and Asia-Pacific regions

BACKGROUND

Paediatric rheumatic diseases are a leading cause of acquired disability in Southeast Asia and Asia-Pacific Countries (SE ASIA/ASIAPAC). The aims of this study were to identify and describe the challenges to the delivery of patient care and identify solutions to raise awareness about paediatric rheumatic diseases.

METHODS

The anonymised online survey included 27 items about paediatric rheumatology (PR) clinical care and training programmes. The survey was piloted and then distributed via Survey-Monkey™ between March and July 2019. It was sent to existing group lists of physicians and allied health professionals (AHPs), who were involved in the care pathways and management of children with rheumatic diseases in SE ASIA/ASIAPAC.

RESULTS

Of 340 participants from 14 countries, 261 participants had been involved in PR care. The majority of the participants were general paediatricians. The main reported barriers to providing specialised multidisciplinary service were the absence or inadequacy of the provision of specialists and AHPs in addition to financial issues. Access to medicines was variable and financial constraints cited as the major obstacle to accessing biological drugs within clinical settings. The lack of a critical mass of specialist paediatric rheumatologists was the main perceived barrier to PR training.

CONCLUSIONS

There are multiple challenges to PR services in SE ASIA/ASIAPAC countries. There is need for more specialist multidisciplinary services and greater access to medicines and biological therapies. The lack of specialist paediatric rheumatologists is the main barrier for greater access to PR training.

Multitasking behaviors and provider outcomes in emergency department physicians: two consecutive, observational and multi-source studies

Background

Multitasking is a key skill for emergency department (ED) providers. Yet, potentially beneficial or debilitating effects for provider functioning and cognition are underexplored. We therefore aimed to investigate the role of multitasking for ED physicians’ work stress and situation awareness (SA).

Methods

Two consecutive, multi-source studies utilizing standardized expert observations in combination with physicians’ self-reports on stress and SA were set out in an academic ED. To control for ED workload, measures of patient acuity, patient counts, and ED staff on duty were included. Regression analyses estimated associations between observed proportion of time spent in multitasking with matched ED physicians’ reports on stress (study 1) and SA (study 2).

Results

ED physicians engaged between 18.7% (study 1) and 13.0% (study 2) of their worktime in multitasking. Self-reported as well as expert-observed multitasking were significantly associated. This confirms the internal validity of our observational approach. After controlling for ED workload, we found that physicians who engaged more frequently in multitasking perceived higher work stress (Beta = .02, 95%CI .001–.03; p = .01). In study 2, ED physicians with more frequent multitasking behaviors reported higher SA (B = .08, 95%CI .02–.14; p = .009).

Conclusions

Multitasking is often unavoidable in ED care. Our findings suggest that ED physicians’ multitasking increases stress experiences, yet, may facilitate professional’s experiences of situation awareness. Our results warrant further investigation into potentially ambivalent effects of ED providers’ multitasking in effectively sharing time between competing demands while maintaining performance and safety.

An Ethics Framework for Making Resource Allocation Decisions Within Clinical Care: Responding to COVID-19

On March, 24, 2020, 818 cases of COVID-19 had been reported in New South Wales, Australia, and new cases were increasing at an exponential rate. In anticipation of resource constraints arising in clinical settings as a result of the COVID-19 pandemic, a working party of ten ethicists (seven clinicians and three full-time academics) was convened at the University of Sydney to draft an ethics framework to support resource allocation decisions. The framework guides decision-makers using a question-and-answer format, in language that avoids philosophical and medical technicality. The working party met five times over the following week and then submitted a draft Framework for consideration by two groups of intensivists and one group of academic ethicists. It was also presented to a panel on a national current affairs programme. The Framework was then revised on the basis of feedback from these sources and made publicly available online on April 3, ten days after the initial meeting. The framework is published here in full to stimulate ongoing discussion about rapid development of user-friendly clinical ethics resources in ongoing and future pandemics.