Acute Health Crisis Research Articles

Global Health \u2013 emergence, hegemonic trends and biomedical reductionism

BackgroundGlobal Health has increasingly gained international visibility and prominence. First and foremost, the spread of cross-border infectious disease arouses a great deal of media and public interest, just as it drives research priorities of faculty and academic programmes. At the same time, Global Health has become a major area of philanthropic action. Despite the importance it has acquired over the last two decades, the complex collective term “Global Health” still lacks a uniform use today.ObjectivesThe objective of this paper is to present the existing definitions of Global Health, and analyse their meaning and implications. The paper emphasises that the term “Global Health” goes beyond the territorial meaning of “global”, connects local and global, and refers to an explicitly political concept. Global Health regards health as a rights-based, universal good; it takes into account social inequalities, power asymmetries, the uneven distribution of resources and governance challenges. Thus, it represents the necessary continuance of Public Health in the face of diverse and ubiquitous global challenges. A growing number of international players, however, focus on public-private partnerships and privatisation and tend to promote biomedical reductionism through predominantly technological solutions. Moreover, the predominant Global Health concept reflects the inherited hegemony of the Global North. It takes insufficient account of the global burden of disease, which is mainly characterised by non-communicable conditions, and the underlying social determinants of health.ConclusionsBeyond resilience and epidemiological preparedness for preventing cross-border disease threats, Global Health must focus on the social, economic and political determinants of health. Biomedical and technocratic reductionism might be justified in times of acute health crises but entails the risk of selective access to health care. Consistent health-in-all policies are required for ensuring Health for All and sustainably reducing health inequalities within and among countries. Global Health must first and foremost pursue the enforcement of the universal right to health and contribute to overcoming global hegemony.

Offline: Health in the unhappy time of COVID-19

It was a tragedy for anyone hoping to see COVID-19 become a catalyst for international solidarity. On the first day of the first-ever virtual World Health Assembly, held during the worst acute global health crisis since WHO's creation in 1948, Alex Azar, US Secretary of Health and Human Services, further damaged the credibility of the US Government as a constructive member of the international community. “We must be frank”, he began. What followed was an astonishing series of unsubstantiated allegations. “There was a failure by this organisation”, Azar stated. He argued that WHO had conspired with a member state (he meant China) “in an apparent attempt to conceal this outbreak”. He accused WHO of unjustly blocking Taiwan's participation at the World Health Assembly. And he said “WHO must change.” It must be more transparent and more accountable. Earlier, WHO Director-General Tedros Adhanom Ghebreyesus gave a forceful defence of the agency. He accepted that “we all have lessons to learn”, but argued that WHO had stood “shoulder-to-shoulder with countries”. The agency had acted quickly, Tedros said. He promised to initiate an “independent evaluation” of the global response. “The world must never be the same.” There was no need for new plans, procedures, or institutions. What mattered now was to strengthen existing mechanisms, especially national public health capacities specified in the 2005 International Health Regulations. Investing in health was a prerequisite for development. To protect the world from future pandemics, Tedros called on member states to support a stronger WHO. In the speeches that followed, countries repeatedly backed WHO and the Director-General. China stressed that it acted in a timely, open, transparent, and responsible manner. Some countries went further, denouncing the unilateral and coercive actions of the US Government. That was on Monday. Overnight, President Trump wrote an explosive letter to WHO's Director-General. He claimed that “the repeated missteps by you and your organization in responding to the pandemic have been extremely costly to the world…if the World Health Organization does not commit to major substantive improvements within the next 30 days, I will make my temporary freeze of United States funding to the World Health Organization permanent and reconsider our membership in the organization. I cannot allow American taxpayer dollars to continue to finance an organization that, in its present state, is so clearly not serving America's interests.” But the basis for his accusations is dubious at best. In his letter, President Trump reports the results of a review his administration conducted into WHO's response to the COVID-19 pandemic. He wrote that “we know the following”. The first allegation he makes is that WHO “consistently ignored credible reports of the virus spreading in Wuhan in early December 2019 or even earlier, including reports from the Lancet medical journal. The World Health Organization failed to independently investigate credible reports that conflicted directly with the Chinese government's official accounts, even those that came from sources within Wuhan itself.” This statement is factually incorrect. The Lancet published no report in December, 2019, referring to a virus or outbreak in Wuhan or anywhere else in China. The first reports the journal published were on Jan 24, 2020. In a paper by Chaolin Huang and colleagues, the first 41 patients from Wuhan with COVID-19 were described. The scientists and physicians who led this study were all from Chinese institutions. They worked with us closely, collaboratively, and quickly to make information about this new epidemic outbreak and disease fully and freely available to an international audience. A second paper, from Jasper Fuk-Woo Chan and colleagues, also published on Jan 24, described the first scientific evidence confirming person-to-person transmission of the new virus. This report included scientists and physicians from Hong Kong and mainland China. The allegations levelled against WHO in President Trump's letter are serious and damaging to efforts to strengthen international cooperation to control this pandemic. It is essential that any review of the global response is based on a factually accurate account of what took place in December and January. It is regrettable that President Trump's letter fell short of these standards. He should retract his letter, correct the record, and withdraw his allegations against WHO.

Traditional Leaders and the 2014–2015 Ebola Epidemic

We assess the role of traditional authorities during an acute health crisis, the 2014–15 Ebola epidemic in Sierra Leone. We exploit plausible exogenous variation in the political competition for lo...

Online Clinical Consultation as a Utility Tool for Managing Medical Crisis During a Pandemic: Retrospective Analysis on the Characteristics of Online Clinical Consultations During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) is a newly-identified infectious diseases that has rapidly spread throughout the world with rising fatalities with declaration by World Health Organization as the pandemic. Online consultations have been shown to alleviate the pandemic with our study aims to demonstrate whether online consultation can be a solution for acute health crisis. Retrospective analysis of the characteristics of online consultations through two primary care online-consultation platforms during COVID-19 pandemic was performed at the Third Affiliated Hospital of Sun Yat-Sen University, which led the assessment of COVID-19-symptoms patients in Guangzhou. The 3473 online consultations were divided into pre-pandemic and pandemic period groups with Chi-square test as statistical analysis method. The number of online consultations has increased with diagnosis of upper respiratory tract infection, psychological conditions, COVID-19-related investigations and interventions. The increased online consultations met the increased demand of the relevant clinical services and reduced the overwhelming hospital presentations, thus decreasing the potential COVID-19 spread inside the major tertiary hospital and sparing the resources for acute crisis management. The epidemiology and disease characteristics of online consultations during the pandemic have been demonstrated with identification of the enabling factors and potential barriers in improving online healthcare in China with online consultation model being a durable solution for pandemic in future.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada

BackgroundThere is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. MethodsDrawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. ResultsAmong 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. ConclusionFindings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Applying principles of injury and infectious disease control to the opioid mortality epidemic in North America: critical intervention gaps.

North America has been experiencing an acute and unprecedented public health crisis involving excessive and increasing levels of opioid-related overdose mortality. In the present commentary, we examine current interventions (as existent mainly in Canada) to date and compare them against established intervention frameworks and practices in other areas of public health, specifically injury and infectious disease control. We observe that current interventions focusing on opioid drug safety or exposure-specifically those that focus on distinctly potent and toxic opioid products driving major increases in overdose mortality-may be considered the equivalent of 'agent-' or 'vector'-based interventions. Such interventions have been largely neglected in favor of 'host' (e.g., drug user-oriented) or 'environmental' measures among strategies to reduce opioid-related overdose, likely contributing to the limited efficacy of current measures. We explore potential reasons, implications and remedies for these gaps in the overall public health strategy employed towards improved interventions to reduce opioid-related health harms.

Couples Adjusting to Multimorbidity: A Dyadic Study on Disclosure and Adjustment Disorder Symptoms.

BackgroundMultimorbidity is challenging not only for the patient but also for the romantic partner. Strategies for interpersonal emotion regulation like disclosing to the partner are supposed to play a major role in the psychosocial adjustment to multimorbidity. Research has often focused on disease-related disclosure, even though disclosing thoughts and feelings related to mundane, everyday life occurrences might also play a role in coadjustment. The current dyadic study aimed at investigating the association between these two types of interpersonal regulation strategies and adjustment disorder symptoms, following the new ICD 11 criteria in multimorbid patients and their partners.MethodsShortly after being hospitalized due to an acute health crisis, N = 28 multimorbid patients (average age 70 years) and their partners filled in questionnaires on disclosure in the couple, adjustment disorder criteria of the ICD 11 (“preoccupation,” “failure to adapt”), and sleep problems.ResultsBoth patients and their partners did show similarly high levels of preoccupation and failure to adapt indicating adjustment problems to the complex health situation. The adjustment symptoms of both partners correlated between r = 0.22 and 0.45. Regression based on Actor-Partner Interdependence-Models revealed that own mundane disclosure was related to less adjustment symptoms in the patients. Beyond that, a partner effect was observed, revealing a negative association between partners’ illness-related disclosure and the patients’ level of preoccupation. For the partners, mundane disclosure of the partner was associated with less preoccupation, failure to adapt, and reported sleep problems above and beyond own disclosure reports. Furthermore, there was an actor effect of disease-related disclosure on less sleep problems for the partners.ConclusionThese results support an interpersonal view on adjustment processes to physical disease. Disclosure as a way of regulating the relationship and emotional responses might play a relevant role here, which seems to be different for patients and their partners. Further research is needed to shed more light on the differential role of disease-related and mundane everyday disclosure for psychosocial adjustment in couples confronted with health challenges.

Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents

ObjectivesMany older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, “no transfer to hospital” ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives. DesignWe conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD). MeasuresADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods. ResultsADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions. Conclusions/ImplicationsThe use of “no transfer to hospital” directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.

Self-management of sick days in young people with type 1 diabetes enhanced by phone support: A qualitative study

Aims and Objectives: The aim of this paper was to evaluate the impact of phone support on sick day management of young people with type 1 diabetes.Method: Qualitative exploratory study to understand the usage of a phone support service available, 8am to 8.30pm, seven days a week. Inclusion criteria were: (a) young people with type 1 diabetes who attend an age-specific service; (b) experienced acute diabetes crisis. Interviews were coded for themes using QSR NVivo™ Version 11 software. Findings were examined through the theoretical lens of the Health Belief Model.Results: Of 20 eligible individuals, 8 participated in the study. Five avoided emergency presentation by accessing the phone support service; three who did not were admitted for diabetic ketoacidosis. The interviews generated 3 major themes: (a) self-efficacy, (b) cues to action, (c) susceptibility.Conclusion: Enhancing self-efficacy and promoting confidence to seek help early during an acute health crisis enables young people to effectively self-manage and avoid hospitalization.

Using spiritual care to alleviate religious, spiritual, and moral struggles arising from acute health crises

Summary Extensive research on religious coping demonstrates that aspects of religion and spirituality may help or harm people going through life crises and trauma. Many people experience religious, spiritual, and moral struggles in coping with crises. While some people are able to draw upon aspects of their religious, spiritual, or moral orienting systems to experience growth in the midst of such struggles, for many people religious, spiritual, and moral struggles are associated with poorer health and well-being. I argue that research on religious, spiritual, and moral struggles ethically compels medical care providers to provide holistic comprehensive care of acute health crises, such that people's beliefs, values, and ways of coping become resources and not liabilities. Healthcare providers, ethically mandated to ‘do no harm’, risk medically neglecting patients by ignoring the religious, spiritual, and moral struggles arising from their acute health crises. What might spiritually oriented care of religious, spiritual, and moral struggles look like? The concept of moral orienting systems is described as a way to practice evidence-based and intercultural care of religious, spiritual, and moral struggles arising from acute health crises.

Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions

ObjectivesTo compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting. DesignQuasi-experimental longitudinal study, with 30-day follow-up. ParticipantsOlder patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis. InterventionsPatients were referred to geriatrician-led HHU or ICGU wards. SettingAn acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. MeasurementsWe compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge. ResultsWe included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P = .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P = >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P = .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P = .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01). ConclusionsThese preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences.

KEEPING SODA IN SNAP: Understanding the Other Iron Triangle.

Participants in SNAP have always been allowed to use their taxpayer-funded benefit to purchase Sugar Sweetened Beverages (SSBs). Despite an acute public health crisis surrounding the consumption of unhealthy products including SSBs, especially among the low-income citizens who also qualify for SNAP benefits, this policy has yet to be changed. Interviews with policy participants in Washington, D.C., reveal that change is being blocked by a culture of "personal responsibility" in America, plus three specific political forces: corporate lobbying primarily by the beverage and food retail industries; a desire by liberals to defend SNAP as income support for the poor even if nutrition outcomes are sub-optimal; and institutional inertia within the Department of Agriculture and the agricultural committees of Congress. In the 2018 farm bill debate, this "iron triangle" of bipartisan resistance to change was strong enough to block even a pilot study of SSB restrictions in SNAP.

Advance Care Planning and its Relevance for Emergency and Intensive Care Medicine

Like in other countries, advance care planning (ACP) is currently being implemented in Germany as a new concept to realise valid and effective advance directives. This concept comprises processes to explore and document individual preferences for future treatment, and to honour them at a time when the person is incapacitated. ACP aims to ensure that patients will be treated according to their preferences when they are no longer capable due to acute health crises or chronic diseases. This paper gives an overview of the concept of ACP with a focus on relevant issues for emergency and intensive care medicine.

Peculiarities of Teaching Problems of Metabolic Syndrome in Children to Interns

Obesity has become one of the most urgent social problems worldwide. Continuous and rapid increase in obesity rates is considered by the World Health Organization as a global epidemic. Obesity affects children as well; the World Health Organization recognized childhood obesity as an acute public health crisis. Childhood obesity is often accompanied by arterial hypertension, hyperlipidemia and disorders of carbohydrate metabolism resulting in symptom complex – metabolic syndrome. While teaching the problems of metabolic syndrome in children to interns, a significant attention is paid to risk factors, diagnosis, treatment and prevention of syndrome. Such approach will allow future pediatricians to diagnose and prevent the development of early complications of metabolic syndrome in children timely.

When Caregiving Ends: The Experiences of Former Family Caregivers of People With Dementia.

Numerous adverse physiological and psychological effects of family caregiving are documented in the literature. However, there is little knowledge about family caregivers after caregiving ends. The purpose of this study is to examine the health of former family caregivers and describe their experiences following the death of a care recipient with dementia. Eight former family caregivers were recruited using convenience sampling. Each caregiver participated in one semi-structured interview ranging from 45 minutes to 3 hours in length. The interviews were audio recorded and transcribed for qualitative content analysis. Three overarching themes emerged from the data: (a) sleep disturbances, (b) changes in health status, and (c) learning to live again. Despite relief from caregiving duties, sleep disturbances in former family caregivers persisted for as long as 10 years post-caregiving. Caregivers reported changes in health such as acute health crises, ongoing illness, or a cascade of nonacute illnesses. Caregivers illustrated post-caregiving as a process of learning to live again, characterized by initial uncertainty about how to proceed in life and a reluctance to relinquish caregiving after years of identifying with the caregiver role. The results of this study suggest that there may be long-term effects of caregiving on health that persist well beyond the first year post-caregiving. Former caregivers would benefit from further research on the physical and psychological health of former caregivers after the first year of post-caregiving, the role of triggering events during post-caregiving, and interventions to meet the needs of former caregivers.

Health Risk Perceptions and Exercise in Older Adulthood: An Application of Protection Motivation Theory.

Protection Motivation Theory (PMT) was applied to explore the relationship between perceived risk of acute health crises and intent to exercise. Interviews of 351 community-living older adults assessed prior physical activity (PPA), all PMT components, and exercise intent. A multi-group structural equation model revealed gender differences in PMT predictors of exercise intent. PPA, age, self-efficacy, and response efficacy directly predicted men's intent. Women's PPA and age predicted PMT components of self-efficacy and response costs, which predicted intent. Findings have implications for devising interventions to enhance physical activity in later life by targeting different PMT components for older men and women.

North Carolina Statewide Telepsychiatry Program (NC-STeP): Using telepsychiatry to improve access to evidence-based care

Mental disorders are common [1] and they are associated with high levels of distress, morbidity, disability, and mortality. We know today that psychiatric treatments work and there is extensive evidence and agreement on effective mental health practices for persons with these disorders. Unfortunately, at a time when treatment for psychiatric illness has never been more effective, many people with these disorders do not have access to psychiatric services due to the shortage, and maldistribution of providers, especially psychiatrists. This has resulted in patients going to hospital emergency departments to seek services resulting in long lengths of stay and boarding of psychiatric patients in hospital emergency departments. A growing body of literature now suggests that the use of telepsychiatry to provide mental health care has the potential to mitigate the workforce shortage that directly affects access to care, especially in remote and underserved areas [2,3].The North Carolina Statewide Telepsychiatry Program (NC-STeP) was developed in response to NC Session Law 2013-360. The vision of NC-STeP is to assure that if an individual experiencing an acute behavioral health crisis enters an emergency department of a hospital anywhere in the state of North Carolina, s/he receives timely, evidence-based psychiatric treatment through this program. Aside from helping address the problems associated with access to mental health care, NC-STeP is helping North Carolina face a pressing and difficult challenge in the healthcare delivery system today: the integration of science-based treatment practices into routine clinical care. East Carolina University's Center for Telepsychiatry is the home for this statewide program, which is connecting 80-85 hospital emergency departments across the state of North Carolina. The plan for NC-STeP was developed in collaboration with a workgroup of key stakeholders including representatives from Universities in NC, hospitals/healthcare systems, NC Hospital Association, NC Psychiatric Association, LME-MCOs, NC-Department of HHS, and many others. The NC General Assembly has appropriated $4 million over two years to fund the program. The program is also partially funded by the Duke Endowment.The program has already connected 56 of the projected 85 hospitals in the first 18 months since its inception and over 12,000 encounters have been successfully completed during this time. A web portal has been designed and implemented that combines scheduling, EMR, HIE functions, and data management systems. This presentation will provide current program data on the length of stay, dispositions, IVC status, and other parameters for all ED patients who received telepsychiatry services. NC-STeP is now positioned well to create collaborative linkages and develop innovative models for the mental health care delivery by connecting psychiatric providers with EDs and Hospitals, Community-based mental health providers, Primary Care Providers, FQHCs and Public Health Clinics, and others. NC-STeP is positioned well to build capacity by taking care of patients in community-based settings and by creating collaborative linkages across continuums of care. By doing so, the program implements evidence-based practice to make recovery possible for patients that it serves.Disclosure of interestThe author has not supplied his declaration of competing interest.

Management of health crisis in nursing homes by adapting hospital-at-home integrated care programs: a local experience from Catalonia

Introduction: It is essential to find new models of care adapted to older residents in social institutions, due to the increasing health complexity of users of these long term care settings. If hospital staff could be effective in managing health crisis in nursing homes, in a more integrated approach, it is unclear. Description of practice: New integrated care units were created in Catalonia, using Intermediate Care resources, in order to manage health crisis of older patients without using conventional hospitalization. A key supportive point of this project for the future is developing hospital-at-home interventions in older patients in the community, including nursing home. Interventions could be run after: a. direct assessment at nursing home or an Emergency Department visit (Admission Avoidance strategy); b. a short hospital stay (Early Discharge strategy). At nursing home, an individualized care plan was defined for each suitable case (medical stability with no severity criteria), sharing objectives with the staff of the setting, in order to stabilize health status and improve conditions associated with acute illness (as functional decline, delirium or nutritional risk). Targeted population and stakeholders: It was developed to attend nursing home residents of the urban area of Badalona, North of Barcelona. A previous analysis found that they have high risk baseline characteristics as old age and multiple chronic conditions related with morbidity and disability. More than a half of the users have low to severe grade of dementia. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117026 – http://www.ijic.org/ A team of specialized hospital health staff and staff from rehabilitation community services developed an innovative program based on Comprehensive Geriatric Assessment for the management of health crisis leading to acute disability in this population, as a local experience. It is being evaluated for future implementation to other areas in Catalonia. Highlights (innovation, impact and outcomes) Innovations:The model of care from acute and postacute geriatric units was adapted to users in the community with a pragmatic approach. Impact: It is an opportunity to maintain highly vulnerable complex older patients in the community, by avoiding hospital admissions o shortening hospital stay in low severity health crisis. Outcomes: N 89 cases attended through 2 years. Main characteristics of patients were (median and IQR or %): age 86 (81-89.5), 77.5% female, number of geriatric conditions 4 (2-6), 57% of patients had dementia. Delirium was detected in 25% of acute health crisis. Main diagnostic groups were: 43% medical, 49% orthopaedic and 8% stroke (Admission Avoidance/Early Discharge strategy: 59/41%). Resolution of health crisis (medical and functional stabilization without hospital readmission) was possible in 80% of cases. Length of hospital-at-home intervention was 46 days. Conclusion: This alternative to conventional hospitalization program in nursing home seems possible and adapted to older patients at risk. Both strategies, admission avoidance and early discharge, could be included, for several medical and surgical conditions. The majority of cases could be managed without new hospitalizations. Discussion: Several organization changes are needed in order to develop this innovative approach. In our experience, hospital staff collaborated with community services, as a functional team. A good targeting process is necessary to avoid risks for patients and nursing homes. Health care technology need to be available to provide intense care outside the hospital. To implement this experience in our social and health system, changes in payment of services need to be considered. Lessons learnt: Integrating hospital care and community services in an individualized intervention in nursing homes for health crisis is an opportunity for the health and social systems. Several changes are needed in order to support implementation of this local experience to the whole system in Catalonia.

Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report.

The BGS recommends that all encounters between health and social care staff and older people in community and outpatient settings should include an assessment for frailty. A gait speed <0.8m/s; a timed-up-and-go test >10s; and a score of ≥3 on the PRISMA 7 questionnaire can indicate frailty. The common clinical presentations of frailty (falls, delirium, sudden immobility) can also be used to indicate the possible presence of frailty. The BGS recommends an holistic medical review based on the principles of comprehensive geriatric assessment (CGA) for all older people identified with frailty. This will: diagnose medical illnesses to optimise treatment; apply evidence-based medication review checklists (e.g. STOPP/START criteria); include discussion with older people and carers to define the impact of illness; work with the older person to create an individualised care and support plan. The BGS does not recommend population screening for frailty using currently available instruments.

Community without solidarity: mercury pollution from small-scale mining and Colombia's crisis of authority

Colombia is the highest per capita emitter of mercury pollution in the world. Ground-level concentrations of atmospheric mercury from small-scale mining in Antioquia, Colombia, are so high that experts fear an environmental health crisis worse than any caused by mercury since Minamata, Japan, in the mid-twentieth century. Gold mining is Colombia's fastest growing industry. While foreign direct investment in gold mining is projected to increase exponentially over this decade, small-scale mining is the major force in the gold sector, generating 50–70 percent of national gold production, 70 percent of which comes from Antioquia. Federal and departmental law calls for miners to curb public exposure to mercury by removing processing activities from urban environments, but the laws are not enforced. This paper examines the political and historical obstacles to enforcing these laws, and explores the dilemmas of solving acute environmental health crises in places where violence, social exclusion and state-failure have crippled institutional legitimacy and authority. The paper addresses uncertainty around whether environmental health and sustainable resource extraction can be vehicles for progressive processes, or if instead, the increased economic emphasis on mining is inseparable from the social and political afflictions that impede environmental policy enforcement.