Clinical Care Research Articles

Improving Newborn Professional Billing at a Community Hospital

INTRODUCTION In community hospital medicine programs, newborns often represent a large patient population with diverse clinical needs. Capturing the care provided through professional billing provides the foundation for division revenue; however, provider knowledge on how to optimally bill is often lacking. Our group underused Hospital Care current procedural terminology (CPT) evaluation and management (E/M) codes for newborns requiring increased monitoring, diagnostic interventions, or therapy. Our aim was to increase use of Level 2 and 3 Hospital Care CPT E/M codes for newborns from 1% to 15%. METHODS The process improvement project was conducted from October 2022 through October 2023 in the mother–baby unit of a community hospital with approximately 1800 births per year. Key drivers for underuse of Hospital Care CPT E/M codes were identified, and interventions were developed that included educational sessions, real-time guidance, and improved access to the billing codes. All newborn initial and subsequent care professional billing codes were included. We used retrospective chart review to determine whether clinical care and documentation supported the use of the codes. RESULTS The proportion of Level 2 and 3 Hospital Care CPT E/M codes increased to 17%. This increase represented a 7% increase in work relative value units and an estimated increase in revenue of $37 805 per 10 000 billing encounters. Review of select charts demonstrated appropriate documentation to support use of the codes 72% of the time. CONCLUSIONS Providing education and tools on professional billing for newborns improved appropriate billing code use and optimized revenue at 1 community hospital.

Comprehensive care processes for substance use disorders in adult mental health services: A systematic review

Background and Objectives: Assessment and care of substance use disorder within mental health services are essential due to the high prevalence and harms associated with comorbidity. Substance use disorder assessment and care are routinely recommended in clinical guidelines; however, processes are not agreed. This systematic review of routine clinical practice in relation to substance use disorders in adult mental health service aims to identify routine assessment and diagnosis processes, the proportion of patients and service episodes in which they occur and their outputs. Methods: We searched MEDLINE, PsycINFO, Embase and relevant Cochrane databases for articles until July 2024 reporting on substance use assessment, diagnosis or treatment in adults receiving routine mental health service and locating additional articles by snowballing. Variables including setting, study method, period, cohort, substances, clinical assessment type, diagnosis and care pathways were compared. Results: In 137 heterogeneous studies reporting routine practice within a wide variety of adult mental health service from 29 nations, 44 (32%) expected or reported on substance use assessment in domains of pattern or impact. However, 23 studies (17%) reported structured approaches to substance use disorder assessment, while 67 (49%) reported a diagnostic structure, including classification system. Diagnostic prevalence varied markedly. Treatment was reported in 16 studies (12%) and no substance use disorder outcomes were reported. Conclusion: This systematic review shows marked variation in routine practice in mental health service across a range of substance use disorder assessment and diagnosis processes. To better identify substance use disorder, enhance its care and reduce associated morbidity, adult mental health service may benefit from standardising expectations and systematically monitoring the performance of substance use assessment and diagnosis.

Brain RNA profiling highlights multiple disease pathways in persons with HAND: uncovering determinants of biotype diversity

Objective: To discover microRNA (miRNA)-RNA transcript interactions dysregulated in brains from persons with HIV-associated neurocognitive disorder (HAND), we investigated RNA expression using machine learning tools. Design: Brain-derived host RNA transcript and miRNA expression was examined from persons with or without HAND using bioinformatics platforms. Methods: By combining next generation sequencing, droplet digital (dd)PCR quantitation of HIV-1 genomes, with bioinformatics and statistical tools, we investigated differential RNA expression in frontal cortex from persons without HIV (HIV[-]), with HIV without brain disease (HIV[+]), with HIV-associated neurocognitive disorder (HAND), or HAND with encephalitis (HIVE). Results: Expression levels for 147 transcripts and 43 miRNAs showed a minimum 4-fold difference between clinical groups with a predominance of antiviral (Type I interferon) signaling-, neural cell maintenance-, and neurodevelopmental disorder-related genes that was validated by gene ontology and molecular pathway inferences. Scale of signal-to-noise ratio (SSNR) and biweight midcorrelation (bicor) analyses identified 14 miRNAs and 45 RNA transcripts, which were highly correlated and differentially expressed (p ≤ 0.05). Machine learning applications compared regression models predicated on HIV-1 DNA, or RNA viral quantities that disclosed miR-4683 and miR-154-5p were dominant variables associated with differential expression of host RNAs. These miRNAs were also associated with antiviral-, cell maintenance-, and neurodevelopmental disorder-related genes. Conclusions: Antiviral as well as neurodevelopmental disorder-related pathways in brain were associated with HAND, based on correlated RNA transcripts and miRNAs. Integrated molecular methods with machine learning offer insights into disease mechanisms, underpinning brain-related biotypes among persons with HIV that could direct clinical care.

Recovery, interrupted: persisting symptoms after concussion and the power of iatrogenesis

ABSTRACT Persisting symptoms after concussion (PSaC) affect up to 30% of children, adolescents, and young adults beyond 1 month post-injury, posing challenges in clinical care. This retrospective study examined 54 patients referred for neuropsychological evaluation due to PSaC, exploring factors contributing to symptom persistence. Results showed that 75.9% of patients experienced symptoms attributable to non-concussion factors, with 90.7% lacking evidence-based care post-injury. Pre-existing conditions, including migraines, anxiety, depression, and other psychiatric disorders, correlated with symptom burden. Linear regression models indicated that these psychiatric factors and the absence of evidence-based recommendations predicted symptom severity [R2 = .314, p = .002], with other psychiatric disorders showing a significant effect [β = 2.28, p = .008]. History of any psychiatric disorder predicted current symptom count [R2 = .121, p = .010]. Logistic regression identified migraines (Nagelkerke R2 = .389, p = .000) and depression (Nagelkerke R2 = .124, p = .033) as predictors of non-concussion etiology. Anxiety, depression, migraines, psychiatric disorders, and lack of evidence-based care predicted non-concussion symptoms (Nagelkerke R2 = .575, p = .000). These findings highlight the importance of holistic, individualized care in concussion. Early neuropsychological involvement may improve diagnosis, reduce iatrogenic effects, and optimize recovery through tailored evidence-based interventions.

Perspectives, Experiences, and Opportunities of Academic Surgeons in the Era of Healthcare Corporatization.

To characterize contemporary surgeons' viewpoints and perspectives on the academic mission during healthcare corporatization. Academic surgery, traditionally driven by the tripartite missions of excellence in clinical care, scientific research, and education, faces increasing challenges from a corporatized healthcare environment. While previous studies have addressed the financial aspects of corporatization, a comprehensive evaluation of academic surgeons' attitudes and experiences remains lacking. An online survey was distributed to a national sample of academic surgical department chairs and program directors assessing their views, perspectives, and experiences with healthcare corporatization. We also analyzed trends in National Institutes of Health (NIH) funding and abstract submissions to the Academic Surgical Congress. Of 105 respondents, 72.9% believe corporatization negatively impacts academic surgery. Among program directors, 79.1% feel corporatization prioritizes clinical productivity over research and teaching. Similarly, 82.8% of department chairs report their faculty often must prioritize clinical duties over other academic responsibilities.Qualitative analysis reveals that surgeons perceive corporatization as a significant barrier to achieving their goals. Many feel that profit has become "king," reducing their roles to "cogs in a wheel."While overall NIH funding increased, the proportion awarded to surgical departments remained largely unchanged from 2006 to 2023 (2.7% vs. 2.8%, P=0.94). Additionally, the proportion of basic science abstracts submitted to the Academic Surgical Congress declined by 37.9%. Corporatization has had a profound impact on surgeons' perceptions of their roles, responsibilities, and autonomy. Surgical departments must take intentional steps to preserve the multidimensional mission of the academic surgeon.

Home-use agents in the treatment of dentin hypersensitivity: clinical effectiveness evaluation with different measurement methods

ObjectivesThis study aimed to evaluate the effectiveness of home-use desensitizing agents over an 8-week period by comparing them using different measurement methods.MethodsA randomized, controlled clinical trial was conducted with 180 individuals aged between 18 and 70 who clinically diagnosed dentin hypersensitivity (DH) in two or more non-adjacent teeth. Subjects who met the inclusion criteria (n = 164) were randomly allocated into five test groups—using Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), Arginine, Novamin, Propolis, and Potassium nitrate—and a control group using standard fluoride toothpaste. The status of DH was assessed at week 4 and week 8 by the same independent examiner. Changes from baseline in Dentine Hypersensitivity Experience Questionnaire-15 (DHEQ-15), Schiff Sensitivity Scale (SSS) and Visual Analog Scale (VAS) were analysed using ANOVA and Kruskall-Wallis tests.ResultsAll test groups showed statistically significant improvements in DH at weeks 4 and 8 compared to baseline in the DHEQ-15, VAS, and SSS assessments (p < 0.005). In the control group, significant improvements were observed only in the VAS and SSS measurements from baseline to weeks 8 (p < 0.005). The CPP-ACP group demonstrated the greatest reduction in scores by the end of week 8 compared to baseline, with DHEQ-15 (56.68 ± 17.87), VAS (6.52 ± 1.48), and SSS (2.32 ± 0.56).ConclusionsAmong the tested agents, the CPP-ACP group demonstrated the most notable reduction in DH symptoms by week 8, highlighting its potential as an effective method for alleviating DH symptoms in a home-use agents.Clinical relevanceHome-use desensitizing agents are effective in the treatment of DH, improving the daily activities of patients who cannot access clinical care and ensuring the relief of DH before clinical invasive procedures.Trial registrationClinicalTrials.gov Identifier: NCT06216262.

Longitudinal qualitative assessment of meaningful symptoms and relevance of WATCH-PD digital measures for people with early Parkinson’s

BackgroundLongitudinal qualitative data on what matters to people with Parkinson’s disease are lacking and needed to guide patient-centered clinical care and development of outcome measures.ObjectiveTo evaluate change over time in symptoms, impacts, and relevance of digital measures to monitor disease progression in early Parkinson’s.MethodsIn-depth, online symptom mapping interviews were conducted with 33 people with early Parkinson’s at baseline and 1 year later to evaluate (A) symptoms, (B) impacts, and (C) relevance of digital measures to monitor personally relevant symptoms. Maps and transcripts were coded for frequencies, Likert scale rankings (0 = not present to 4 = most bothersome), and thematic findings. Wilcoxon Signed Rank test was used to evaluate change over time.ResultsOther than walking and balance, most motor symptoms did not change significantly from baseline to 1 year later. Multiple significant changes were observed in non-motor areas (cognition, speech, sleep, mood, fatigue, pain; p < 0.05) and functional impacts (mobility, effort to do usual activities, personal comfort; p < 0.05). Thematic analysis revealed ability to cope with and compensate for actual or anticipated symptoms reduced disruptions to well-being and changed how bothersome symptoms were. All digital measures targeted symptoms that were personally important to most participants (> 80%).ConclusionNon-motor and walking/balance symptoms changed sooner than other motor symptoms during the course of 1 year. Evaluation of coping and compensatory mechanisms may be essential to understanding symptom bothersomeness at a given point in time. Smartphone and smartwatch digital measures were relevant to personally meaningful symptoms of early PD.

Caregiver perceptions of usual care home programs for persons with acquired brain injury: a qualitative descriptive study

ObjectiveThe study explores caregiver perceptions of home programs for clients with acquired brain injury based on current clinical care after transition to the community.DesignA qualitative descriptive study.SettingWithin the community, post inpatient rehabilitation.ParticipantsA convenience sample of eight caregivers of clients with acquired brain injury from one clinical site. All participants spoke English, were between the ages of 18 and 85 years, had no neurodegenerative disorders, and self-identified as caregivers.ProceduresTwo nested semi-structured interviews were completed post-discharge from an inpatient rehabilitation facility. All interviews were audio recorded and transcribed. Qualitative data analysis was performed utilizing MAXQDA© software, consensus coding, and abstraction of themes.ResultsTwo themes with subsequent subthemes were identified: (1) Systems, Roles, and Responsibilities Influenced Caregivers' Perceptions of Home Program and Recovery Outlook and (2) Caregivers' Home Program Experience. The first theme addresses topics of caregiver roles and responsibilities, system supports and barriers, and their general outlook on recovery. Within the second theme, results provide a chronological description of home program training, use, and modification.ConclusionsA caregiver’s outlook on the care receiver’s recovery and home program implementation is influenced by the burden of responsibilities, and system-level supports and barriers. The home program experience of the caregivers was reported to involve limited but satisfactory training. Caregivers saw the value in home programs and advised others to engage in them. Future programs should encourage healthcare providers to provide explicit instruction to the caregiver about their intrinsic value to home program implementation and adherence.

Methodological challenges using routine clinical care data for real-world evidence: a rapid review utilizing a systematic literature search and focus group discussion

BackgroundThe integration of real-world evidence (RWE) from real-world data (RWD) in clinical research is crucial for bridging the gap between clinical trial results and real-world outcomes. Analyzing routinely collected data to generate clinical evidence faces methodological concerns like confounding and bias, similar to prospectively documented observational studies. This study focuses on additional limitations frequently reported in the literature, providing an overview of the challenges and biases inherent to analyzing routine clinical care data, including health claims data (hereafter: routine data).MethodsWe conducted a literature search on routine data studies in four high-impact journals based on the Journal Citation Reports (JCR) category “Medicine, General & Internal” as of 2022 and three oncology journals, covering articles published from January 2018 to October 2023. Articles were screened and categorized into three scenarios based on their potential to provide meaningful RWE: (1) Burden of Disease, (2) Safety and Risk Group Analysis, and (3) Treatment Comparison. Limitations of this type of data cited in the discussion sections were extracted and classified according to different bias types: main bias categories in non-randomized studies (information bias, reporting bias, selection bias, confounding) and additional routine data-specific challenges (i.e., operationalization, coding, follow-up, missing data, validation, and data quality). These classifications were then ranked by relevance in a focus group meeting of methodological experts. The search was pre-specified and registered in PROSPERO (CRD42023477616).ResultsIn October 2023, 227 articles were identified, 69 were assessed for eligibility, and 39 were included in the review: 11 on the burden of disease, 17 on safety and risk group analysis, and 11 on treatment comparison. Besides typical biases in observational studies, we identified additional challenges specific to RWE frequently mentioned in the discussion sections. The focus group had varied opinions on the limitations of Safety and Risk Group Analysis and Treatment Comparison but agreed on the essential limitations for the Burden of Disease category.ConclusionThis review provides a comprehensive overview of potential limitations and biases in analyzing routine data reported in recent high-impact journals. We highlighted key challenges that have high potential to impact analysis results, emphasizing the need for thorough consideration and discussion for meaningful inferences.

Longitudinal Insights Into Childhood Onset Facioscapulohumeral Dystrophy: A 5-Year Natural History Study.

Facioscapulohumeral dystrophy (FSHD) is an inherited muscle disorder, with childhood onset in 20% of patients. Understanding the natural history of childhood FSHD and identifying clinical and functional outcome measures are crucial for clinical care and future trials. In a prospective nationwide FSHD cohort study (iFocus), 20 childhood-onset patients were assessed at baseline, 2 years, and 5 years. Assessments included manual muscle and functional muscle tests, FSHD clinical score (FSHD-CS), FSHD clinical severity scale (FSHD-CSS), and muscle ultrasonography (MUS). Eighteen patients (aged 2-17 years at baseline) completed the 5-year follow-up. Disease progression varied, with a mean FSHD-CS increase of 1.6. Despite objective disease progression, most participants (89%) did not perceive change. The most sensitive outcome measures were FSHD-CS (standardized response mean [SRM] 1.07), FSHD-CSS score (SRM 0.92), and MUS findings (SRM 0.68). Baseline characteristics did not predict progression. Disease progression was variable and often remained unnoticed by participants. Quality of life improved, and fatigue levels decreased over 5 years. The relatively slow progression and physiologic growth highlight the need for sensitive end points within a 1-2-year time frame. Future pediatric studies should consider larger international cohorts, assess reachable workspace, and include MUS and FSHD functional composite outcome measure (FSHD-COM).

Evaluating Access to Neuropsychological Services for Individuals With Spina Bifida: Insights From the 2022 Provider Survey

Background: Many people with spina bifida (SB) have congenital brain malformations and receive neurosurgical intervention that can impact cognitive, behavioral, and emotional functioning. The Spina Bifida Association's (SBA) guidelines for care recommend that people with SB have neuropsychology evaluations to assess cognitive, behavioral, and emotional functioning throughout their lifespan; however, people with SB anecdotally report having trouble finding and accessing such care. Objectives: The goal of this study was to gain information about neuropsychology services available to people with SB and identify possible barriers to care. Methods: Neuropsychologists in the United States were invited to complete a practice-focused survey created by members of the Spina Bifida Neuropsychology Collaborative (SBNC). The survey was emailed to professional neuropsychology listservs and directly to providers at the SBA Clinic Care Partner and National Spina Bifida Patient Registry (NSBPR) sites. Results: Responses from 34 neuropsychologists (representing 22 sites, including 40% of SBA Clinic Care Partner sites and 67% of NSBPR sites) indicated that multilingual SB-focused neuropsychology services are available within all regions of the United States. Comprehensive, outpatient evaluations are common; however, integration of neuropsychology services into inpatient settings and multidisciplinary clinics is limited. Respondents report that waitlist time is the most frequent barrier to neuropsychology care, followed by cost/insurance/payor type, travel/transportation difficulties, and limited referrals. Conclusion: There are considerable gaps in the currently available array of US-based neuropsychology services for individuals with SB. Neuropsychologists and SB clinical programs are encouraged to strategically increase availability of neuropsychological services and expand care options.

The Evaluation of Biochemical Parameters in Positive COVID-19 RealTime PCR Patients: A Retrospective Study

Coronavirus, a member of the beta coronavirus family, encompasses a range of illnesses from common colds to severe disorders. SARS-CoV-2, transmitted mainly through respiratory droplets that are generated by a patient who is sneezing, coughing and talking, caused the global pandemic COVID-19 in 2020. The virus primarily targets the respiratory system especially in the lung cell, leading to diverse symptoms and severe consequences. This study was carried out in the COVID-19 Isolation Centre in Mukalla City, Yemen, to evaluate biochemical tests in COVID-19 patients. In the retrospective single-centre study on 116 COVID-19 patients, some of biochemical Analysed Parameters were glucose, Liver function tests, renal function tests, lipid profile, and proinflammatory markers; convenience sampling based on existing records for socio-demographics, medical history, and biochemistry were analysed by using a spectrophotometry and Chemiluminescent immunoassay analyser. used SPSS version 25 to analyse data. Most COVID-19 patients in Mukalla City (91.4 % of those over 46 years old) have common symptoms such as fever, cough, and respiratory problems. The study found links between chronic health disorders (hypertension 96.6 %, diabetes mellitus 94.8 %) and greater vulnerability to COVID-19. Blood glucose levels substantially impact COVID-19 occurrences (p 0.0001). Some liver function tests are associated with COVID-19 (total protein, albumin, LDH, and GGT) (p = 0.044, 0.010, 0.0001, and 0.0001, respectively). Urea and creatinine levels imply renal function and their significant association (p=0.001 for both), whereas uric acid had no significant association with COVID-19 (p = 0.134). However, lipid profile tests lack statistical significance; they do identify trends. Proinflammatory markers CRP and ferritin strongly correlate with positive COVID-19 patients (p=0.0001 for both). In conclusion, COVID-19 significantly affects glucose metabolism, liver function, renal dynamics, and inflammatory markers, necessitating vigilant monitoring for clinical care and informing future research.

Utility of Protein Markers in COVID-19 Patients

COVID-19 has been a challenge at the healthcare level not only in the early stages of the pandemic, but also in the subsequent appearance of long-term COVID-19. Several investigations have attempted to identify proteomic biomarkers in an attempt to improve clinical care, guide treatment and predict possible patient outcomes. Proteins such as C-reactive protein (CRP) or interleukin 6 (IL-6) are clear markers of severe disease, but many others have been proposed that could help in risk stratification and in the prediction of specific complications. This review aims to bring together the most relevant studies in this regard, providing information to identify the most notable biomarkers in relation to COVID-19 found to date.

Improving Cognitive Empathy Through Traumatic Brain Injury Experiential Learning: A Novel Mixed Methods Approach for Speech-Language Pathology Graduate Education.

The aim of this study was to gauge the impacts of cognitive empathy training experiential learning on traumatic brain injury (TBI) knowledge, awareness, confidence, and empathy in a pilot study of speech-language pathology graduate students. A descriptive quasi-experimental convergent parallel mixed methods design intervention pilot study (QUAL + QUANT) was conducted with a diverse convenience sample of 19 first- and second-year speech-language pathology graduate students who engaged in a half-day TBI point-of-view simulation. The simulation was co-constructed through a participatory design with those living with TBI based on Kolb's experiential learning model and followed the recommendations for point-of-view simulation ethics. After setting goals, participants engaged in four station activities completing cognitive communication activities of daily living, while experiencing manipulations to their sensory systems. Activities included reading while wearing goggles with blurred or double vision, listening with tinnitus and auditory processing disorder, and taking notes during a manipulated college lecture. Participants also interacted with an individual living with TBI and responded to targeted prompts throughout the day. Quantitative outcomes were measured using published TBI knowledge and empathy scales and analyzed with descriptive, parametric and nonparametric statistics, while qualitative data were analyzed through thematic analysis. Data were then triangulated through mixed methods. Mixed methods design quality was ensured by following the Mixed Methods Appraisal Tool (Hong et al., 2018). After experiential learning, significant increases in speech-language pathologist (SLP) TBI knowledge, empathy, and awareness of TBI symptom and symptom impacts were found. Many, but not all, participants also reported changes in clinical confidence. Cognitive empathy training using experiential learning appears to be a viable method to increase SLP knowledge, empathy, and symptom awareness for TBI clinical care. Future research should replicate the study with different types and locations of speech-language pathology graduate programs to consider TBI empathy training as a standard training method to improve both individual and provider outcomes. Individuals and families living with traumatic brain injury (TBI) say their providers lack necessary knowledge; do not seem to understand what living with TBI is like; and can be dismissive, uncaring, and lacking empathy. Health care providers do not automatically imagine the world from the patient's perspectives, to "walk in another's shoes"; it takes intentional effort and training. This project attempted to train those specific empathy skills for speech-language pathology graduate students through experiential learning. Experiential learning is a process where people engage in meaningful activities and spend lots of time reflecting on their experiences. Working with people living with TBI, we built a half-day workshop where 19 graduate students completed normal daily activities (such as texting, reading) through different stations that provided insights into what it may be like to have a TBI, such as wearing goggles to induce blurred or double vision, having ringing in their ears (tinnitus), and watching an overwhelming manipulated college video lecture. Afterward, participants listened to a person living with TBI and asked questions. This was important because engaging in activities without interacting with someone living with TBI misses a key idea about listening to and learning from individuals and families. We measured TBI knowledge, empathy, and confidence by looking at surveys pre- and posttraining and reading students' written reflections. Participants reported significant changes in how they think about brain injury and how they will provide clinical care for people living with TBI in the future. https://doi.org/10.23641/asha.28098254.

Investigating misclassification of type 1 diabetes in a population-based cohort of British Pakistanis and Bangladeshis using polygenic risk scores

Correct classification of type 1 (T1D) and type 2 diabetes (T2D) is challenging due to overlapping clinical features and the increasingly early onset of T2D, particularly in South Asians. Polygenic risk scores (PRSs) for T1D and T2D have been shown to work relatively well in South Asians, despite being derived from largely European-ancestry samples. Here we used PRSs to investigate the rate of potential misclassification of diabetes amongst British Bangladeshis and Pakistanis. Using linked health records from the Genes & Health cohort (n = 38,344) we defined two reference groups meeting stringent diagnostic criteria: 31 T1D cases, 1842 T2D cases, and after excluding these, two further groups: 839 insulin-treated diabetic individuals with ambiguous features and 5174 non-diabetic controls. Combining these with 307 confirmed T1D cases and 307 controls from India, we calculated ancestry-corrected PRSs for T1D and T2D, with which we estimated the proportion of T1D cases within the ambiguous group at ~ 6%, dropping to ~ 4.5% within the subset who had T2D codes in their health records (and are thus most likely to have been misclassified). We saw no significant association between the T1D or T2D PRS and BMI at diagnosis, time to insulin, or the presence of T1D or T2D diagnostic codes amongst the T2D or ambiguous cases, suggesting that these clinical features are not particularly helpful for aiding diagnosis in ambiguous cases. Our results emphasise that robust identification of T1D cases and appropriate clinical care may require routine measurement of diabetes autoantibodies and C-peptide.

Comparison of a Novel Ultra-Widefield Three-Color Scanning Laser Ophthalmoscope to Other Retinal Imaging Modalities in Chorioretinal Lesion Imaging.

To compare the assessment of clinically relevant retinal and choroidal lesions as well as optic nerve pathologies using a novel three-wavelength ultra-widefield (UWF) scanning laser ophthalmoscope with established retinal imaging techniques for ophthalmoscopic imaging. Eighty eyes with a variety of retinal and choroidal lesions were assessed on the same time point using Topcon color fundus photography (CFP) montage, Optos red/green (RG), Heidelberg SPECTRALIS MultiColor 55-color montage (MCI), and novel Optos red/green/blue (RGB). Paired images of the optic nerve, retinal, or choroidal lesions were initially diagnosed based on CFP imaging. The accuracy of the imaging was then evaluated in comparison to CFP using a grading scale ranging from -1 (losing imaging information) to +1 (gaining imaging information). Eighty eyes of 43 patients with 116 retinal or choroidal pathologies, as well as 59 eyes with optic nerve imaging using CFP, MCI, RG, and RGB, were included in this study. Across all subgroups, RGB provided significantly more accurate clinical imaging with CFP as ground truth and compared to other modalities. This was true comparing RGB to both RG (P = 0.0225) and MCI (P < 0.001) overall. Although RGB provided more accurate clinical information overall, it was inferior to RG for melanocytic choroidal lesions (P = 0.011). RGB can be considered as a useful tool to detect characteristics of central, midperipheral, and peripheral retinal lesions. Regarding melanocytic choroidal lesions, RGB was inferior to RG, and MCI was inferior to both RG and RGB modalities due to color changes. Traditional retinal ultra-widefield imaging uses two wavelengths. Here, we evaluated three wavelengths for ultra-widefield imaging. We examined new optics (basic science) effect on patient imaging (clinical care).

Perceptions of Clinical Connectedness Among Hospital Environmental Service Workers.

Environmental service workers (ESWs) have a critical role within the hospital infrastructure and are at the frontline of infection prevention. ESWs are highly trained in managing all forms of regulated waste, which includes biohazardous waste, and are responsible for the overall patient experience, janitorial work, and infection prevention. Without environmental services, patients have a 6 times greater risk of being infected by pathogens from patients who previously occupied their room. To understand how ESWs felt proud, connected, and not connected to their hospital-based clinical teams. This qualitative study included 10 ESWs who were members of clinical care teams at a medical university hospital in upstate New York. Data were collected from February to May 2024. Participants were asked to take pictures and write vignettes about what makes them feel proud of their work, how they feel connected to their clinical team, and how they feel disconnected from their clinical team. This study included 10 participants (5 males [50%]; 10 non-Hispanic Black or African American individuals [100%]; mean [range] age, 53 [38-66] years; 8 were high school graduates or had some college credit [80%]). When asked about their feeling of pride, participants expressed maintaining a clean space, having meaningful relationships, and helping others as generating a sense of pride. Participants' feelings of disconnectedness were felt by their colleagues not following the rules set in place. In addition, participants reported feeling invisible, not listened to, unappreciated, and undervalued. Participants felt connected to their clinical teams by feeling a sense of community, having valuable relationships, and being able to communicate with members of the clinical team. Additionally, participants expressed a collective desire to be acknowledged, recognized, and treated as equals on the clinical team. The study found that ESWs identified feeling both connected to and disconnected from their clinical teams. Based on these results, hospital infrastructure and leadership should continue to exhaust all efforts to explore work experiences of ESWs to improve job retention, morale, satisfaction, overall clinical teamwork, and comradery.

Novel Method for Routine Ultrasound-Guided Serum Collection for Biomarker Analysis Around the Knee Joint

Background Biomarkers are essential tools in modern medicine, allowing stratification and monitoring of clinical care and treatment response. While systemic blood biomarkers, typically collected from the antecubital vein (AV), are widely used, their sensitivity for joint-specific pathologies such as osteoarthritis (OA) may be limited due to systemic dilution. At present, no serum biomarker reliably reflects the microenvironment of an affected joint in clinical practice. Although synovial fluid (SF) assessment can provide insights into localised pathology and are clinically used for diagnosis in crystal arthropathies and joint infections, their collection is invasive, painful, and carries risks, including infection, making repeated sampling impractical, limiting utility for monitoring treatment responses. This study introduces a novel ultrasound-guided venous sampling technique targeting the saphenous vein (SV) proximal to the knee joint as a less invasive alternative to SF aspiration, hypothesising that it may better reflect the joint-specific microenvironment. Methods A standardised gel model was used to train medically qualified researchers in ultrasound-guided venepuncture of vescles around 2-15 mm in diameter. Subsequently, 32 participants consented to blood sampling from the SV above the knee, with a proximally applied tourniquet to dilate vein diameter for easier venepuncture collection. Results The technique achieved serum collection in over 80% of consented individuals with minimal adverse effects (including n=2 minor bruising and n=1 transient nerve irritation). Key procedural insights included optimal site selection, appropriate pressure application, and effective tourniquet use. Discussion This method demonstrates feasibility, acceptability, and the potential for more localised sample collection, advancing biomarker research. Further validation, including paired SF comparisons, is required to confirm diagnostic utility and develop therapeutic strategies for joint-specific conditions.

Cardiovascular Anesthesia and Critical Care in the French West Indies: Historical Evolution and Current Prospects

Anesthesiology, the medical specialty that deals with the management of vital functions in patients undergoing surgery, has played an important role in the successful development of cardiac interventions worldwide. Tracing the historical roots of cardiac anesthesia and critical care from its inception in the late 1950s, a paradigm shift in perioperative care has been driven by a better understanding of the mechanisms of organ dysfunction in stressful conditions and technological advances regarding surgical approach, patient monitoring, and organ protection. Although progress in cardiac anesthesia and critical care lagged a little behind in Caribbean territories, successful achievements have been accomplished over the last forty years. Compared with Western countries, the greater prevalence of obesity, diabetes mellitus, and hypertension as well as specific diseases such as cardiac amyloidosis, sickle cell anemia, rheumatic heart disease, and tropical infections may reduce a patient’s physiologic reserve and increase the operative risk among the multi-ethnic population living in the French West Indies and Guiana. So far, cardiac anesthesiologists at the University Hospital of Martinique have demonstrated their abilities in implementing evidence-based clinical care processes and adaptating to efficiently working in a complex environment interacting with multiple partners. Attracting specialized physicians in dedicated cardiac surgical centers and the creation of a regional health network supported by governmental authorities, insurance companies, and charitable organizations are necessary to solve the unmet needs for invasive cardiac treatments in the Caribbean region.

Antidopaminergic medications in Huntington's disease

Huntington's disease (HD) is a progressive neurodegenerative disorder marked by motor, cognitive, and behavioral impairments. Antidopaminergic medications (ADMs), such as VMAT2 inhibitors and antipsychotics, are commonly used to manage HD motor disturbances and behavioral disorders. For patients and caregivers, ADMs are an important tool for managing symptoms that negatively affect daily life. However, the impact of ADM use in HD is not firmly understood due to a lack of robust, systematic studies that assessed their overall effect on HD disease. A mounting body of evidence suggests these medications may be associated with worse clinical measures of cognitive function and functional impairment. While regulatory guidelines highlight adverse effects like sedation, cognitive dysfunction, and extrapyramidal symptoms, it is unclear whether ADMs directly impact disease progression or if the side effects mimic or exacerbate measures of HD symptoms in clinical trials. Given ADM effects on the central nervous system and biological uncertainty within HD outcomes, clinical trial designs should recognize the impact of ADMs on key outcomes, as measured by acceptable scales including Total Functional Capacity, Stoop Word Reading, Symbol Digit Modality Test, and the composite Unified Huntington's Disease Rating Scale. The development of novel HD interventions requires consideration of concomitant ADM use that may influence measures of disease presentation. In this review, we highlight the role of ADMs in HD management, their symptomatic benefits and potential risks, especially with high dose associated side effects, interactions with CYP2D6 inhibitors, and the individualized need for careful dose monitoring for clinical care and trial design.