Appropriate Level Of Care Research Articles

Systematic Review: Mental Health Screening Tools for Collegiate Athletes

The mental health of college athletes has become a priority for the National Collegiate Athletic Association (NCAA) and for athletic departments across numerous Colleges and Universities. Sport social work has limited research exploring empirical evidence on the use and effectiveness of specific mental health assessments for the population of college athletes. College athletes experience a plethora of stressors and mental health concerns that will require the use of mental health assessments to determine the appropriate level of care. A systematic review was conducted utilizing the Cochrane Handbook of Systematic Reviews for Interventions. An initial search of sport social work literature yielded 1,199 articles. After the application of inclusion and exclusion criteria, five articles remained that met the full criteria for inclusion. Results indicate there are mental health assessment tools that have empirical data supporting their use with college athletes. Although appropriate mental health screening tools were identified, future research is necessary to expand the breadth of empirical data that supports additional mental health assessment tools for specific use with the population of college athletes. These tools should include a positive psychology component to reduce the stigma surrounding mental health care in the college athlete population and increase their likeliness to engage in mental health services.

Thromboelastogram changes are associated with postoperative complications after cytoreductive surgery.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is used to treat peritoneal surface malignancies. However, surgical morbidity is high, and prediction of severe postoperative complications (SPC) is limited. We hypothesized that the changes in thromboelastogram (TEG) values following CRS could be associated with SPC. We retrospectively analyzed a cohort of CRS and HIPEC patients who had TEG measured before and after CRS. Clinical and postoperative data were retrieved from a prospectively maintained database. Our 37-patient cohort was comprised of 24 men and 13 women with an age (median, [interquartile range, IQR]) 55 (47-65) years, of whom six had SPC. The ones with SPC did not differ from the others in age, sex, tumor histology or preoperative chemotherapy. The extent of surgery as measured by the peritoneal carcinomatosis index and the number of organs resected was comparable between SPC group vs. no SPC [9 (3-10.5) vs. 9 (5-14), p=1.0; 2 (0.75-2.25) vs. 2 (1-3), p=0.88, respectively]. The TEG parameters showed increased R- and K- time for the patients with SPC compared to those without (6±3.89 vs. 4.05±1.24, p=0.01; 1.65±0.63 vs. 1.25±0.4, p=0.03, respectively). The TEG values were significantly associated with SPC in the multivariable analysis (odds ratio=1.53, p=0.05). TEG changes are associated with SPC. Intra-operative markers of SPC could guide intraoperative decisions, such as stool diversion and postoperative triage of patients to an appropriate level of care.

Development and internal validation of prehospital prediction models for identifying intracerebral haemorrhage in suspected stroke patients

IntroductionDistinguishing patients with intracerebral haemorrhage (ICH) from other suspected stroke cases in the prehospital setting is crucial for determining the appropriate level of care and minimising the onset-to-treatment time, thereby...

Neonatal presentations in the pediatric emergency department: A decade-long retrospective analysis

BackgroundThe global increase in neonatal visits to Pediatric Emergency Departments (PEDs) underscores the need to better understand the factors driving these visits and their implications. The often vague and nonspecific symptoms of neonates pose significant challenges for clinicians and caregivers in determining the appropriate level of care, impacting the frequency of return visits and overall effectiveness of discharge education. ObjectiveThis study aims to compile the most common chief complaints of neonates in the PED and analyze their association with admission rates and final ED diagnoses to inform educational interventions for caregivers and medical personnel. MethodsThis was a retrospective review of data from medical records from neonatal (≤30 days of life) presentations to the PED at a quaternary care medical center in Portland, Oregon, USA from January 2012 to December 2022. Results3175 patient encounters were identified, of which one-third (38 %) were admitted to the hospital. The most frequent 25 chief complaints are shown in Table 1. Certain complaints had higher admission rates than the average: temperature instability (71 % for “fever” and 89 % for “hypothermia”), breast concerns (68 %), abnormal lab results (63 %), “seizures” (53 %), and cardiac concerns (54 %). Notably, neonates presented on DOL 0 and DOL 1 had elevated admission rates of 77 % and 66 %, respectively. ConclusionThis study identified specific complaints that were most likely to result in hospital admissions and return visits to the ED. This can guide targeted educational interventions for caregivers and ED providers and refinement of triage protocols to ensure that neonates receive the most appropriate and efficient care.

SMART Medical Review: Acute Pancreatitis Assessment and Management in the First 24 Hours

Acute pancreatitis (AP) is an inflammatory reaction of the pancreas caused by inappropriate trypsin activation and an injury / innate inflammatory response. The many etiologies and potentially life-threatening consequences of AP require that clinicians initiate prompt and individualized treatment upon diagnosis. Application of new advances in the management of AP are required at the point of care. To facilitate care, a group of clinical experts have developed a set of recommendations for the evaluation and management of AP during the first 24 hours based on current evidence and evolving concepts. Ten areas of care are addressed where expert recommendations may be useful: (1) physical examination, (2) laboratory tests, (3) diagnosis, (4) early treatment, (5) severity determination, (6) etiology-based management, (7) typical orders sets, (8) determining of appropriate level of care, (9) quality of care, and (10) quality improvement recommendations. Conclusion: These recommendations should become available as clinical decision support tools that are accessible at the point of care, in real time.

632. CAN CARDIOPULMONARY EXERCISE TESTING PREDICT NEOADJUVANT CHEMOTHERAPY TOXICITY IN OESOPHAGEAL ADENOCARCINOMA PATIENTS?

Abstract Background Cardiopulmonary exercise testing (CPET) is a method of assessing cardiopulmonary fitness. In the context of surgery, it is used to risk-stratify patients, allowing targeted prehabilitation to optimise comorbidities and fitness prior to surgery, and triage patients to the appropriate level of care after the operation. Various CPET-derived variables have been shown to be associated with short- and long-term outcomes after various surgery. In patients post-oesophagectomy, these variables are predictive of long-term survival. This study aimed to assess the use of this tool to predict neoadjuvant chemotherapy (NAC) related complications in patients receiving neoadjuvant FLOT prior to oesophagectomy. Methods All patients who underwent routine CPET during the staging process prior to NAC with FLOT and oesophagectomy in a single high-volume centre between September 2018 and January 2023 were included. Data were extracted from the unit’s contemporaneously maintained database. The Mann-Whitney U test was used to compare CPET variables in patients who completed NAC with FLOT fully versus those who did not finish NAC with FLOT due to acute chemotherapy toxicities. Results There were 129 patients who received neoadjuvant FLOT and had routine CPET performed during the defined study period. Six of those patients (4.7%) did not complete neoadjuvant chemotherapy due to acute chemotherapy toxicities but progressed to surgery. The median anaerobic threshold, VO2 peak, and VE/VCO2 among those who completed NAC were 14.2 ml/kg/min, 20.3 ml/kg/min, and 28, respectively, compared to 13.4 ml/kg/min, 19.7 ml/kg/min, and 31 in those who did not complete NAC (p=0.595, p=0.695, and p=0.160, respectively). Conclusion Although patients who received all four cycles of NAC with FLOT prior to oesophagectomy demonstrated CPET values indicating better base-line fitness than those who had to discontinue NAC due to acute chemotherapy toxicity, these differences did not reach the level of statistical significance. This study, therefore, did not demonstrate any predictive value of CPET in assessing the risk of incomplete NAC treatment prior to oesophagectomy.

Whale are our kin, our memory and our responsibility

There is a global move to advocate for the incorporation of Indigenous Knowledges into conservation and land management programs. In Australia this is being reflected in some programs and also regularly in strategy documents. However, we argue that this rarely reflects self-determination for Traditional Custodians. In this article we use two Culturally Significant Entities (CSEs), the humpback and southern right whales, to demonstrate how the regulatory framework that is in place to support species conservation does not adequately allow for Traditional Custodians to extend culturally appropriate levels of care for Country or preserve the knowledge held or associated with a species. Our aim is that the Australian Government and people will work with us to find a way to support the care of CSEs. Position statement We, the authors, are Indigenous Australians. We have familial connections to whale Lore Holders and/or hold traditional whale Lore/Law as part of our cultural obligations. It is from this position that we advocate for greater care of the whales with which we have Ancestral kinship and reciprocal responsibility.

Screening, Brief Intervention and Referral to Treatment (SBIRT): An examination of health disparities

Risky substance use can lead to a variety of negative health outcomes, yet treatment is often underutilized by historically minoritized racial/ethnic groups. Screening, Brief Intervention and Referral to Treatment (SBIRT) is effective in changing substance use patterns across diverse settings and for diverse demographic groups. However, few studies have focused on whether individuals receive the appropriate level of care based on screening criteria. The purpose of this study was to investigate intervention match/mismatch and factors (e.g., service site, gender, race, ethnicity, age, socio-economic status) that predicted the likelihood of being matched/mismatched to an intervention. A sample of N = 3412 were available for analyses and logistic regressions were performed to examine the relationship between matching/mismatching to an intervention and other factors. Of participants, 2222 (65%) were matched to an intervention and 1190 (35%) were mismatched to an intervention. Being older, Hispanic, and receiving SBIRT by health-teams designed to reduce health disparities was related to increased odds of being mismatched. Exploratory results suggested that across predictors, individuals were more likely to receive a lesser intervention than their screening score indicated. Most clients were matched well to intervention as based on screening score. When mismatch occurred, a lower level of care was given. Staff may benefit from attending to more client engagement so that clients return for more intensive interventions; and agencies may need more resources to facilitate client access to services.

Using AI-based virtual triage to improve acuity-level alignment of patient care seeking in an ambulatory care setting

Objective: Evaluate how an AI-based virtual triage (VT) and care referral technology impacted live triage and care referral in an outpatient/ambulatory care network.Methods: Analysis of a dataset of 8,088 outpatient online encounters assessed how VT influenced patient care seeking action/behavior.Results: There were modest decreases in patients seeking outpatient care, including in-person or video face-to-face encounters (-12.5%), or engaging self-care (-8.2%). Patient engagement of virtual care through e-visits and telephone calls increased moderately (19.1%). One-third (35.0%) of patients changed care seeking likely as a result of VT care referral. Another third (32.3%) reported a pre-VT care intent aligned with the VT care recommendation, and a third (32.7%) did not change care sought when their pre-VT intent was not aligned. A total of 12.0% de-escalated acuity of care seeking as recommended by VT, most frequently from outpatient care to virtual care (6.5%) or self-care (4.3%). When VT recommended care de-escalation, 53.5% de-escalated care. In 21.2% care acuity was escalated, of whom 10.6% pursued virtual care and 7.5% pursued outpatient care instead of self-care, while 3.1% whose care intent was virtual care instead pursued outpatient care. When VT recommended care escalation, 96.2% escalated care. Overall, 26.7% of patients required no further action or involvement of clinical staff.Conclusions: Virtual triage impacted patient care seeking action/behavior among almost half of patients whose pre-VT intent differed from the VT recommendation, with patients nearly twice as likely to follow recommendations to seek higher rather than lower levels of care acuity, while modestly reducing the number of face-to-face visits and increasing virtual care. Overall, a quarter of patients using VT were able to perform self-care without interacting with the healthcare team. Virtual triage has the potential to efficiently and effectively redirect patients to more appropriate levels of care.

The Role of SARS-CoV-2 Nucleocapsidic Antigen and Krebs von den Lungen 6 Serum Levels in Predicting COVID-19 Pneumonia Outcome.

The COVID-19 pandemic caused by SARS-CoV-2 continues to pose a significant threat worldwide, with severe cases leading to hospitalization and death. This study aims to evaluate the potential use of serum nucleocapsid antigen (NAg) and Krebs von den Lungen-6 glycoprotein (KL-6) as biomarkers of severe COVID-19 and to investigate their correlation with clinical, radiological, and biochemical parameters. This retrospective study included 128 patients with confirmed SARS-CoV-2 infection admitted to a Neapolitan hospital in Italy between October 2020 and July 2021. Demographic, clinical, and laboratory data were collected, including serum levels of NAg and KL-6. The Chung et al. Computed Tomography Severity Score (TSS) was used to assess the severity of pneumonia, and outcomes were classified as home discharge, rehabilitation, and death. Statistical analyses were performed to compare Group I (home discharge and rehabilitation) and Group II (death, sub-intensive care, and ICU stay) based on demographic data, laboratory parameters, and TSS. Group II patients showed worse outcomes with higher levels of NAg, KL-6, and inflammatory markers, including interleukin-6 (IL-6), interleukin-2 receptor (IL-2R), and adrenomedullin. TSS was also significantly higher in Group II, with a positive correlation between TSS and NAg and KL-6 levels. Group I patients had higher values of hemoglobin (Hb) and platelets (PLT), while Group II patients had higher values of C-reactive protein (CRP), procalcitonin (PCT), D-Dimer, and glycemia. No significant difference was observed in gender distribution. Serum NAg and KL-6 levels are potential biomarkers of severe COVID-19 pneumonia, with higher levels indicating greater inflammation and organ damage. NAg may help identify infected patients at an increased risk of severe COVID-19 and ensure their admission to the most appropriate level of care. KL-6 may help predict interstitial lung damage and the severity of clinical features. Further studies are needed to establish a decision-making cut-off for these biomarkers in COVID-19.

Substance use disorder-associated infections' treatment with dalbavancin enabling outpatient transition (SUDDEN OUT) - an investigator-initiated single-arm unblinded prospective cohort study.

Severe gram-positive infections are frequent in people who inject drugs, and successful completion of treatment presents unique challenges in this population. We aimed to evaluate the feasibility of a long-acting antibiotic, dalbavancin, as an alternative to standard-of-care antibiotics for severe infections due to vancomycin-susceptible pathogens requiring ⩾2 weeks of therapy. We designed an investigator-initiated single-arm unblinded prospective cohort study to evaluate the safety and efficacy of an early switch to dalbavancin in two doses administered 1 week apart. We screened patients admitted with bloodstream infection, osteomyelitis, septic arthritis, infective endocarditis or deep abscesses, and comorbid substance use disorder (SUD) for eligibility. Consenting patients were switched to dalbavancin within 7 days from their index culture. They were monitored in the hospital for efficacy and safety of the treatment until the second dose of dalbavancin 7 days later and then discharged if stable. Study participants were evaluated with a decision support engine for a hypothetical appropriate level of care regarding their SUD after discharge. Their follow-up was planned for 12 months from the index culture, either in-person or via telehealth/telephone. The enrollment was terminated early due to significant loss-to-follow-up. In all, 11 patients were enrolled, 4 completed 12 months of follow-up, 2 completed 8 months of follow-up, and 1 was seen once after discharge. The remaining five patients were lost to follow-up immediately after discharge. All 11 patients continued to improve after switching to dalbavancin between the first and second doses. There were two per-protocol failures of treatment. Dalbavancin was well tolerated, though some adverse events were reported. Dalbavancin may be a safe and effective alternative for an early switch in treating severe gram-positive infections. The trial was registered as NCT04847921 with clinicaltrials.gov.

Hospital-to-Home: logic model and theory of change exercise to identify outcomes arising from integrated health and social care.

Introduction: Although Canada boasts universal access to hospital-based services, bed capacity has been a challenge with long wait times for acute admissions to a hospital bed from the Emergency Department. The use of hospital beds by ‘alternate level of care’ (ALC) patients is a critical concern. These ALC patients exist because of a lack of an appropriate level of care in the community. Integrated health and social care (IHSC) can limit avoidable acute care utilization including in-patient stays in hospitals. CHATS--Community & Home Assistance to Seniors is a community-based agency that provides transportation, meals, in-home services, caregiver relief, education and support, community wellness, and 24/7 assisted living among other services, with the aim of supporting ageing in place. CHATS has partnered with several local hospitals and homecare providers to create a number of hospital-to-home programs (HTH) that provide seamless and coordinated care from hospital to home for older adults enabling safe and effective transitions. Hospital-based data has shown that ALC days and inpatient and ED hospital readmissions declined following implementation of HTH programs. Although hospital-based data is available, community-based health and social care outcome-based metrics have not been developed nor collected. Despite limited qualitative data showing high levels of client and caregiver satisfaction with its HTH services, the lack of outcome-based data makes it difficult for CHATS to articulate the benefits of the HTH programs from a community-based perspective that reflects both health and social care outcomes with the aim of informing policy and programming decisions in the future, including program scale and spread.
 Methodology: A logic model (LM) and theory of change (ToC) exercise was undertaken by a broad representation of CHATS staff at all levels of the organization to identify the theory of change for the HTH programs and critical activity-based and outcome-based metrics to support future measurement and evaluation work. The development of these models clarified the fundamental program theory behind community agency contributions to the HTH programs that enable their success.
 Results: The theory of change noted that the HTH program was able to achieve hospital to home transition success because it facilitates older adult clients to achieve greater self-determination that can support more independent living. The HTH program’s components, case management, personal support, transportation, training, counselling, and assessments ensure that the personal goals of clients and their caregivers are identified and addressed. Feelings of empowerment, improved mental health, health and social care navigation literacy, and reduced acute care readmissions are some of the outcomes perceived as being attributable to the HTH programs. These outcomes, in turn, allow for greater overall health and wellbeing, and sense of independence among older adult clients and their caregivers. Ultimately, the HTH programs contribute towards greater systems efficiency and enhanced quality of life for clients and their family/caregivers.
 Next steps: The results of the LM and ToC exercises have enabled CHATS to identify critical input, activity and outcome measures for the HTH programs that reflect the contributions of CHATS, and a towards a future summative evaluation of the HTH programs.

Healthy Aging in Algoma: Tests of Change Program

Introduction: In Algoma District, Ontario, Canada, approximately 25% of the population is 65 years of age and older. The Ontario Provincial Geriatrics Leadership Office (2020) predicts that by 2040 this number will increase to 32% and that 29% of older adults will be living with frailty. In February of 2022, Tests of Change (ToC) Program work commenced to bring an integrated care approach to healthy aging in Algoma. Healthcare member organizations of the Algoma Ontario Health Team (AOHT) and community patient, family, and caregiver advisors identified older adults living with frailty as the target population. A driver diagram of change ideas was conceptualized to support improving care for the identified population. To enact the recommended changes, three priority projects - Outpatient Geriatric Rehabilitation Capacity, Coordinated Access to Geriatric Services and Early Frailty Identification - complement each other with the common purpose of improving early frailty intervention and increasing access to the most appropriate care.
 Aims: The ToC Program entails:
 Embedding a frailty screening tool into electronic medical records for use in primary care;
 Initiating coordinated access to geriatric services leveraging eReferral and a common platform for electronic referral management; and
 Designing an outpatient geriatric rehabilitation program.
 This Program aims to advance the following elements:
 Design upstream engagement strategies (e.g., screening, prevention, disease self-management) for the target population;
 Increase patient access to the appropriate level of care; and
 Transform care coordination, transitions and recovery at home.
 Highlights: The AOHT has engaged partners from across the continuum of care who provide services for frail older adults. Partners include: community support services, home and community care support services, primary care, acute care, specialized geriatric services, and patient advisors. These critical partners assume leadership roles in program design, implementation and evaluation.
 Conclusions: Early frailty identification can improve quality of life, increase intervention success, and delay the need for specialist care. This program is predicated on the establishment of foundational processes enabled by digital tools to identify frailty early, streamline referrals for access to the most appropriate geriatric services, and provide patients with the opportunity to fully participate in interventions such as outpatient geriatric rehabilitation to increase their ability to live independently in the community. By taking an integrated collaborative approach to program planning and execution, overall patient outcomes will be improved.
 Transferability: The WHO Guidelines on Integrated Care for Older People (ICOPE) recommend advancing integrated care through community collaboration, a patient centered approach and supportive leadership. In 2019, the Ontario Health Team (OHT) model was introduced provincially as a way for healthcare providers to partner to deliver coordinated, integrated care. Of significance, several of the 54 approved OHTs have identified older adults living with frailty as a target population. Globally, as older adults are living longer lives, it is anticipated that there will be proportionally more older adults living with frailty. Through collaboration and sharing of the ToC program results, program scalability can be achieved at the OHT level and support the global knowledge base on efforts to strengthen integrated care for older adults.

Initial programme theory development: The first step in a realist evaluation of a cross-sectoral intervention for expectant Danish parents living with psychosocial risks.

A distinct inequality in maternity care exists, and women with psychosocial risks are at a greater risk of adverse birth outcomes. In several high-income countries, a psychosocial risk assessment early in pregnancy is recommended so that expectant parents are offered an appropriate level of care which facilitates relevant, tailored interventions for those in need. In 2017, a cross-sectoral and interdisciplinary intervention for expectant parents with psychosocial risks was developed and implemented in the North Denmark Region. The development process of the intervention has not been reported and theory-based knowledge about how supportive interventions bring about change for expectant parents with psychosocial risks is scarce. Through the initial phase of a realist evaluation, we aimed to elicit key contexts and mechanisms of change regarding the intervention for expectant parents with psychosocial risks. Through an initial programme theory, this article illustrates how, for whom and in which contexts the intervention is intended to work. Data is comprised of intervention documents, 14 pilot observations and 29 realist interviews with key stakeholders. A thematic analytical approach inspired by retroductive thinking was applied to identify and analyse patterns related to the incentive of the intervention, its structure, intended outcomes, generative mechanisms and contextual matters. Generative mechanisms responsible for bringing about change in the intervention were identified as healthcare professionals' approach, continuity, trust, early intervention and social network. Cross-sectoral collaboration and healthcare professionals' competencies were assumed to be central stimulating contextual factors. The initial programme theory developed in this study will serve as the basis for further refinement via empirical testing in a later phase of the realist evaluation.

Que faut-il retenir des recommandations de bonne pratique de la HAS 2022 : « Obésité de l’adulte : prise en charge de 2e et 3e niveaux – Partie I : prise en charge médicale » ?: What to remember from the HAS 2022 best clinical practice recommendations: Obesity in adults: “2nd and 3rd levels of care management – Part I:

Presently in France, more than 8 million people are affected by obesity (17% of the French population), with an even higher prevalence among people from disadvantaged socio-economic backgrounds. This pathology requires a global, multi-professional, multimodal, adapted, and exhaustive management, taking into account all the associated comorbidities and the potential handicap caused by the severity of obesity. These best practice clinical recommendations, published in 2022, improves the management of patients with obesity through: (i) the development of a new clinical classification that graduates the severity of obesity beyond the sole BMI, allowing patients to be referred to the appropriate level of care; (ii) the exhaustive description of the evaluation content (medical, behavioral, psychological and social); (iii) the precision of the objectives and content of the needed therapeutic lifestyle modifications and (iv) the introduction and description of anti-obesity drug indications. These recommendations were then used by another working group to propose a guide for the care pathway of adults living with overweight and obesity (published in February 2023), and to broaden the indications for drug treatments for obesity (opinion on drugs, December 2022). Finally, these recommendations will be completed by a second part concerning the revision of the bariatric surgery recommendations (expected in 2024) in order to propose uniform and quality management of patients living with obesity.© 2023 Société francophone nutrition clinique et métabolisme (SFNCM).Published by Elsevier Masson SAS. All rights reserved.

Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use

New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Assessment of Knowledge Regarding Antenatal Care among Men in Selected Rural Areas of Himachal Pradesh

Background: WHO defined health as the state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity, but it includes ability to lead socially and economically productive life.1 Being a man or women has a significant impact on health, as a result of both biological as well as gender related differences. Antenatal care (ANC) is most important aspect of women‘s reproductive health. The antenatal care is the care provided by skilled health care professionals to pregnant women and adolescent girls to ensure best health conditions for mother and baby during pregnancy. It reduces maternal and perinatal morbidity and mortality both directly, through detections and indirectly, through the identification of women and girls at increased risk of developing complications during labour, delivery and ensuring appropriate level of care.1 As per NFHS- 4, the 21% of pregnant women utilised full ANC, ranging from 2.3–65.9% across states. Overall, 51.6% had 4 or more ANC visits, 30.8% consumed IFA for at least 100 days and 91.1% had one or more doses of tetanus toxoid. Full ANC utilisation was inequitable across place of residence, caste, and maternal education. Registration of pregnancy, utilisation of government‘s Integrated Child Development Services (ICDS) and health insurance coverage were associated with higher odds of full ANC utilisation. Lower maternal education, lower wealth quintile, lack of father‘s participation during antenatal visits, higher birth order, teenage and unintended pregnancy were associated with lower odds of full ANC utilisation. This study assesses the knowledge about the antenatal care among married and unmarried men of 18-35 years age in selected rural areas of Himachal Pradesh. Methods: The study was an unmatched case and control design where married men were considered as a case and unmarried men as comparator group. This study was a part of large study for which sample size of 268 men in each group was calculated assuming prevalence of female contraceptives 70% in unmarried men and 85% in married men. This was carried out by cluster-based sampling in villages of Nagrota Bagwan and Shahpur health blocks of DRPGMC Tanda at Kangra. Results: The 93.3% participants among case group are aware of anaemia in pregnancy while only 64.9% among control group are aware of anaemia in pregnancy. The knowledge about all three causes of anaemia was statistically more in case group (61.9%) as compared to control group (38.8%). Assessment about high-risk pregnancy, about 72.4% participants among case group were aware about the risk factors in pregnancy as compared to 43.3% in control group with statistically significant differences (P=0.000). All the causes of high-risk pregnancy were reported by the participants of case group (44.0% vs 29.9%) with statistically significant differences. Conclusions: Married men had significantly more knowledge about various components of antenatal care. The awareness approach for unmarried men needs to be designed regarding antenatal care.

Role of emergency teleradiology in a mass motorcycle event: the experience of the 2021 International Six Days of Enduro (ISDE).

Provision of healthcare support at mass gathering sporting events is of paramount importance for the success of the event. Many of such events, like motorsports, have been increasingly taking place in remote and austere environments. In these settings, the use of first-line diagnostic tools, such as point of care ultrasound and portable X-ray, could aid in definitive care on the field for patients with minor trauma while also ensuring fast access to the appropriate level of care for patients requiring hospitalization. As part of the ISDE 2021 medical response plan, a field hospital equipped with portable digital X-ray and telemedicine was established. Data on patient admission, triage, treatments, diagnostics, and outcomes were collected for analysis. During the 6-day competition, 79 patients sought medical care at the field hospital, with traumatic injuries accounting for 77% of cases. Of these, 47 were athletes and 32 were non-athletes. The majority (91%) arrived spontaneously, while 9% were transported directly. Upon admission, 68 patients were triaged as non-urgent (code 3) and 11 as urgent (code 2). Of those admitted, 69 received treatment and were discharged at the field hospital, while 10 were transferred elsewhere. Notably, four patients had major trauma, two had isolated fractures, and one needed a CT scan after losing consciousness. Overall, 29 missions were conducted on the race field, including 13 primary transports to local hospitals and 6 to the field hospital. Primary transport was primarily due to major trauma. Among 31 patients who had radiological exams, 11 (35.5%) had traumatic injuries. Of these, 5 were treated with braces and casts and discharged without hospitalization, 3 were advised for post-event care, and 3 were hospitalized. In contrast, patients with negative X-rays received on-site treatment, with 7 able to continue competing. In summary, the successful implementation of portable X-ray machines and teleradiology at remote and austere high-risk sporting events holds great promise for enhancing on-site medical capabilities, allowing clinicians informed decisions, avoiding unnecessary hospitalization, and allowing athletes to continue with their competition. Provided that challenges related to cost, safety, connectivity, and power supply are effectively addressed.

Integrated behavioral health services in pediatric primary care and emergency department utilization for suicide risk.

Universal screening for suicide risk in primary care settings is a promising avenue for preventing self-harm and improving health outcomes. Triaging youth to an appropriate level of care, including diverting lower-risk patients from the emergency department (ED) is a meaningful goal. Previous research indicates integrated behavioral health (IBH) may prevent unnecessary admission to the ED on the day of suicide risk screening. We hypothesized that youth who received an IBH consultation the same day as suicide risk screening would be less likely to be admitted to the ED, but more likely to contact IBH services and utilize primary care in the following month. We conducted a retrospective chart review of 3,649 youth aged 10-18 years who were screened with the Ask Suicide-Screening Questions (ASQ) in two pediatric primary care practices. We collected demographic data, ASQ and Patient Health Questionnaire-9 (PHQ-9) scores, as well as patient contacts with IBH, the ED, and medical primary care the day of screening and the following 31 days. We conducted a series of logistic regressions and chi-square analyses to determine whether contact with IBH on the same day as positive suicide risk screenings predicted same-day admission to the ED, IBH contact, and medical primary care utilization. Among the 7,982 ASQ scores, 1,380 (18%) were non-acute and 87 ASQs (1%) screened acutely positive. Over 90% of positive screens were diverted from the ED regardless of IBH contact. None of the patients died from suicide. Same-day IBH was associated with higher likelihood of general ED visits for all positive screens (acute and non-acute together). None of the positive screens that received an IBH consultation on the same day as screening were admitted to the ED in the subsequent month. Contact with IBH the same day as screening positively predicted utilization of IBH and medical primary care services in the subsequent month, especially for youth with minority race and ethnicity identities. In the context of clinics with IBH and systematic risk assessment processes, most youth who screen positive for suicide risk are diverted from the ED. However, contrary to our hypothesis, our study showed that youth who received same-day IBH consultations were more likely to be admitted to the ED compared to peers who did not receive IBH consultations. These findings suggest that systematic suicide screening combined with IBH consultations in pediatric primary care can effectively identify risk levels and triage patients to appropriate care.

Predicting the risk of in-hospital Asian NSTEMI patients using stacked ensemble learning

Abstract Background NSTEMI affects 60–75% of patients with MI and has a variety of clinical manifestations and prognoses. Ensemble learning (EL) utilizes the machine learning (ML) models on a classification task to make more accurate predictions than any single ML model. It has also been demonstrated to be superior to conventional risk scores in predicting mortality risk. However, no studies on the application of EL to ASIAN NSTEMI patients have been published. Purpose To identify factors associated with Asian in-hospital NSTEMI patients using ML and to develop a stacking EL-based NSTEMI risk score that is specifically tailored to the Asian population. Methods From 2006 to 2016, 10464 data were collected from the Malaysian National Cardiovascular Disease Database (NCVD-ACS) registry on hospitalized multiethnic Asian patients admitted with NSTEMI. This study utilized 39 variables, including demographic, cardiovascular risk, medication, and clinical variables. For stacked EL model development, four algorithms, Support Vector Machine (SVM), Random Forest (RF), eXtreme Gradient Boosting (XGB), and Naive Bayes (NB), are used as base learners, and Generalized Linear Model (GLM) is used as the meta learner. Significant variables were chosen and ranked using ML variable importance with backward elimination. As a predictive performance metric, the area under the curve (AUC) was used. Using a validation dataset, algorithms were validated against the TIMI for NSTEMI, and the net reclassification index (NRI) was calculated. Results The stacked EL models developed using SVM feature selection (13 predictors, AUC = 0.823, CI: 0.779 - 0.867) outperforms the conventional risk score, TIMI (AUC = 0.563, CI: 0.515 - 0.610). RF contributes the most to the EL model predictions, followed by NB, XGB and SVM (Figure 1). Common predictors between SVM feature selection and TIMI are; age, hypertension and ECG-type depression. SVM feature selection also identified gender, MI history, chronic lung disease, heart rate, systolic blood pressure, Killip class, fasting blood glucose, LMWH, beta-blockers and angiotensin II receptor blocker as predictors that improve mortality prediction in ASIAN NSTEMI patients. Our findings indicate that the TIMI score underestimates the mortality risk of NSTEMI patients. Stacked EL model using selected predictors classified 47.4% of nonsurvivors as high risk (risk probabilities > 50%), whereas TIMI (score > 5) classified only 3.3% of nonsurvivors as high risk (Figure 2). The NRI of NSTEMI patients using the EL model (SVM selected var) resulted in an NRI of 79.8% with a p-value < 0.00001 when compared to the TIMI for NSTEMI risk score. Conclusions The stacked EL algorithm classifies ASIAN NSTEMI patients more accurately than the single ML model and TIMI score. A precise prognosis is useful for selecting the appropriate level of care and pharmacological or invasive treatment for patients with Asian NSTEMI.Relative influence of each ML modelsStacked EL performance on validation set