Considerable Care Research Articles

The impact of social deprivation on rotator cuff repair outcomes

BackgroundRotator cuff tears are a common orthopedic injury and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair. MethodsWe conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level one academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADI scores, range of motion, visual analog pain scores, and patient-reported outcomes (SST, ASES, and QuickDASH) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using ANOVA, t-tests, chi-square tests, and univariate/multivariate logistic regression. Results322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (p<0.001). Massive tear occurrence was greater in the least deprived group (p=0.003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH) were worse in the most deprived group compared to the least and intermediate deprived groups. ConclusionSocial deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. While clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

Palliative care in kidney transplant recipients with graft failure.

Kidney transplantation is the best renal replacement therapy for patients with end stage kidney disease. It provides longer patient survival and better quality of life than dialysis. The clinical course after kidney transplantation could be complex and variable. Patients may develop various complications or even kidney graft failure. Symptom burden related to uraemia in patients with graft failure, and the side-effects of immunosuppression, cause psychological distress and adversely affect the quality of life of patients. Treatment decisions in patients with graft failure can be challenging to patients and their caregivers. Renal palliative care is an emerging field, but its adoption remains relatively low among kidney transplant recipients with progressive graft failure. In this context, timely consideration and referral for palliative care can improve symptom burden, reduce stress in patients and their caregivers, and facilitate treatment goal setting and advanced care planning. Common barriers to bring palliative care to suitable patients include: (I) misconception in patients, caregivers and healthcare providers that palliative care means abandonment of life sustaining treatment; (II) over-optimistic prognostic assessment and over-aggressive management approach; (III) insufficient awareness and training in palliative care of healthcare professionals; (IV) inadequate access to and insufficient resources in palliative care. Enhanced training and awareness, and further studies, would be needed to optimize the decision process and delineate the benefit of palliative care, and to guide evidence-based practice in the transplant population.

Marginal and Obsolete? Rural Hospitals in Early Modern Europe: A Case Study of Catalonia

Summary Small local hospitals have been neglected by historians, and frequently assumed to have been marginal to their communities and largely obsolete by the eighteenth century. This paper questions such assumptions via a case study of Catalonia. It provides the first comprehensive estimates for the number of hospitals over the course of the eighteenth century, and then examines a sample of surviving accounts and other documentation to analyse the extent and nature of care provided. While the quality of care varied and most hospitals were restricted by their income, particularly against a background of war and rising prices, many nevertheless provided considerable care both to transient populations of foundlings and migrants and to their local communities. The paper calls for a re-evaluation of these forms of care in line with the re-evaluation of women’s caring work.

Ketamine Use for Palliative Care in the Austere Environment: Is Ketamine the Path Forward for Palliative Care.

The goal of palliative care is to focus on the holistic needs of the patient and their family versus the pathology of the patient's diagnosis to reduce the stress of illness. U.S. servicemembers deployed to austere environments worldwide have significantly less access to palliative care than in military treatment facilities in the U.S. Preparation for future conflicts introduces the concept of prolonged medical management for an environment where urgent casualty evacuation is impossible. Ketamine is currently widely used for analgesia and anesthesia in the care of military service members and its use has increased in combat zones of Iraq and Afghanistan due to the favorable preservation of respiratory function, minimal changes in hemodynamics, and lower pain scores compared to opioids. Ketamine acts as a non-competitive antagonist on N-methyl-D aspartate (NMDA) receptors. Its anesthesia and analgesic effects are complex and include both presynaptic and postsynaptic neurons in brain and spinal cord. The use of palliative care to minimize suffering should not be withheld due to the logistical boundaries of austere military environments or lack of guidelines for recommended use. The use of ketamine for palliative care is a new clinical management strategy to provide both sedation and pain management for an acute pain crisis or comfort measures for the terminally ill. This makes ketamine an attractive consideration for palliative care when managing critically wounded patients for an extended time.

Updates on disorders in curly hair.

Hair disorders, including central centrifugal cicatricial alopecia (CCCA), traction alopecia (TA), and acquired trichorrhexis nodosa (ATN), commonly occur in individuals with curly textured hair. Curly textured hair in individuals of African descent has unique properties and can present diagnostic and therapeutic challenges. CCCA has been linked to uterine leiomyoma and type 2 diabetes mellitus, as well as fibroproliferation. TA often presents with a fringe sign and can arise from high-tension hairstyles presumed to be protective. Trichoscopy is useful in establishing a diagnosis; perifollicular halos are more commonly seen than perifollicular erythema or scale in CCCA. In TA, miniaturized follicles, hair casts, and "flambeau sign" can be seen. Hairstyling practices likely contribute to TA and ATN; however, the data are mixed on the role of chemical relaxers and heat styling in CCCA. Unique considerations in the presentation of frontal fibrosing alopecia in curly textured hair have also been published recently. This review provides a comprehensive, up-to-date summary of these disorders with an emphasis on their unique properties, as well as considerations in hair care for curly textured hair.

Second Primary Breast Cancer in Young Breast Cancer Survivors

Among women diagnosed with primary breast cancer (BC) at or younger than age 40 years, prior data suggest that their risk of a second primary BC (SPBC) is higher than that of women who are older when they develop a first primary BC. To estimate cumulative incidence and characterize risk factors of SPBC among young patients with BC. Participants were enrolled in the Young Women's Breast Cancer Study, a prospective study of 1297 women aged 40 years or younger who were diagnosed with stage 0 to III BC from August 2006 to June 2015. Demographic, genetic testing, treatment, and outcome data were collected by patient surveys and medical record review. A time-to-event analysis was used to account for competing risks when determining cumulative incidence of SPBC, and Fine-Gray subdistribution hazard models were used to evaluate associations between clinical factors and SPBC risk. Data were analyzed from January to May 2023. The 5- and 10- year cumulative incidence of SPBC. In all, 685 women with stage 0 to III BC (mean [SD] age at primary BC diagnosis, 36 [4] years) who underwent unilateral mastectomy or lumpectomy as the primary surgery for BC were included in the analysis. Over a median (IQR) follow-up of 10.0 (7.4-12.1) years, 17 patients (2.5%) developed an SPBC; 2 of these patients had cancer in the ipsilateral breast after lumpectomy. The median (IQR) time from primary BC diagnosis to SPBC was 4.2 (3.3-5.6) years. Among 577 women who underwent genetic testing, the 10-year risk of SPBC was 2.2% for women who did not carry a pathogenic variant (12 of 544) and 8.9% for carriers of a pathogenic variant (3 of 33). In multivariate analyses, the risk of SPBC was higher among PV carriers vs noncarriers (subdistribution hazard ratio [sHR], 5.27; 95% CI, 1.43-19.43) and women with primary in situ BC vs invasive BC (sHR, 5.61; 95% CI, 1.52-20.70). Findings of this cohort study suggest that young BC survivors without a germline pathogenic variant have a low risk of developing a SPBC in the first 10 years after diagnosis. Findings from germline genetic testing may inform treatment decision-making and follow-up care considerations in this population.

JC Virus in Kidney Transplant Population: Are We Cautious Enough?

The John Cunningham virus (JCV) is a polyomavirus that usually infects people at a young age and does not cause any symptoms in immunocompetent individuals. However, in immunocompromised individuals, such as kidney transplant recipients, JCV can cause severe and potentially fatal disease. Unfortunately, JCV has not been researched as extensively as the BK virus and is not mentioned in relevant kidney transplant guidelines. This lack of attention to JCV can lead to less consideration in kidney transplant patients' care. Surveillance using locally available diagnostic methods is of the utmost importance. The presence of JCV can be diagnosed with urine decoy cells, viruria, or viremia verified by the PCR method. A low threshold for considering JCV as a possible cause of any neurological or renal dysfunction in kidney transplant recipients must be maintained. In such cases, kidney and brain biopsy are indicated. Maintaining the appropriate immunosuppression while avoiding over-immunosuppression to prevent JCV disease is crucial, and the approach should be individual, according to overall immunological risk. We hypothesize that the presence of the JCV can indicate overt immunosuppression and identify kidney transplant recipients more prone to opportunistic infections and diseases, including some malignancies. To explore that, future observational studies are needed.

War related disruption of clinical tuberculosis services in Tigray, Ethiopia during the recent regional conflict: a mixed sequential method study

BackgroundMore than 70% of the health facilities in Tigray, northern Ethiopia, have been totally or partially destroyed by the recent war in the region. Diagnosis and management of tuberculosis were among many health services that suffered. In this study we assess the status of tuberculosis care in health facilities of Tigray during the recent war and compare it with the immediate pre-war state.MethodsUsing sequential mixed method, we analyzed and compared the availability of diagnostic services in 69 health facilities and the utilization of tuberculosis care in 50 of them immediately before the war (September-October 2020) and during the war (November-July 2021). TB focal persons in each selected health facility were interviewed to evaluate the status of diagnostic services. Patient service utilization was assessed using health facility registrations. We also compared the average monthly case detection rate of multidrug resistant tuberculosis in the region before and during the war. We computed summary statistics and performed comparisons using t-tests. Finally, existing challenges related to tuberculosis care in the region were explored via in-depth interviews. Two investigators openly coded and analyzed the qualitative data independently via thematic analysis.ResultsAmong the 69 health facilities randomly selected, the registers of 19 facilities were destroyed by the war; data from the remaining 50 facilities were included in the TB service utilization analysis. In the first month of the war (November 2021) the number of tuberculosis patients visiting health facilities fell 34%. Subsequently the visitation rate improved steadily, but not to pre-war rates. This reduction was significant in northwest, central and eastern zones. Tuberculosis care in rural areas was hit hardest. Prior to the war 60% of tuberculosis patients were served in rural clinics; this number dropped to an average of 17% during the war. Health facilities were systematically looted. Of the 69 institutions assessed, over 69% of the microscopes in health centers, 87.5% of the microscopes in primary hospitals, and 68% of the microscopes in general hospitals were stolen or damaged. Two GeneXpert nucleic acid amplification machines were also taken from general hospitals. Regarding drug resistant TB, the average number of multidrug resistant tuberculosis (MDR TB) cases detected per month was reduced by 41% during the war with p-value < 0.001. In-depth interviews with eight health care workers indicated that the main factors affecting tuberculosis care in the area were lack of security, health facility destruction, theft of essential equipment, and drug supply disruption.Conclusion and recommendationMany tuberculosis patients failed to visit health facilities during the war. There was substantial physical damage to health care facilities and systematic looting of diagnostic equipment. Restoring basic public services and revitalizing clinical care for tuberculosis need urgent consideration.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations.

Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75years or older. Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

A Systemwide Strategy to Embed Equity into Patient Safety Event Analysis

There is a lack of framework to incorporate equity into event analysis. This quality improvement initiative involved the development of equity tools that were introduced in a two-hour interactive, case-based training across 11 acute care facilities at the largest municipal health care system in the United States. A pre and post survey (which included analysis of a clinical vignette) was also conducted to assess for knowledge and comfort embedding equity in patient safety event analysis, and to measure discomfort or distress during the training. A separate assessment was used to evaluate the tools. A visual aid, the Patient Equity Wheel, was created to facilitate more comprehensive and robust health equity discussions by compiling a comprehensive list of equity categories, including internal, external, and organizational dimensions of equity. The Wheel was designed for use during each phase of event analysis. An Embedding Equity in Root Cause Analysis Worksheet was developed to aid in assessing considerations of equitable care in the investigation process and includes questions to ask staff to further assess bias or equitable care factors. Participant knowledge and level of comfort increased after training. The most commonly unrecognized categories of bias were Training/Competencies, Structural Workflow, and Culture/Norms. Most participants responded that they had no discomfort or distress during the training. Post-training feedback noted that the tools were being used across the system in various stages of event analysis and have been reported to improve health equity conversations.

Private Equity in Distress and the Incentives of Collateralised Loan Obligations

Abstract This article explores the problem that both modern private equity (PE) firms, and collateralised loan obligation (CLO) lenders to PE portfolio companies, have incentives to avoid a formal restructuring of PE portfolio companies in financial distress. The author is concerned that this may lead to negative social costs for suppliers, employees, customers and even government agencies. She explores how and why the problem arises, and the ways in which corporate and corporate insolvency law might be able to respond to it. Some suggestions are made, but it is accepted that any solution involves a sensitive balance that needs to be approached with considerable care.

Exploring the value of a structured trauma-pathway in improving traumainformed care within a Veterans’ High Intensity Service

IntroductionThe value of using trauma-informed approaches in the way services and systems deliver care is well recognised. This evaluation aimed to consider the value of using a structured ‘trauma pathway’ to improve trauma informed care within a veterans’ high intensity service.MethodA mixed-methods design was employed. Practitioners completed questionnaires via an online platform and also attended a focus group to share their views. Qualitative data were analysed using inductive thematic analysis.ResultsA total of 14 team members were eligible to take part. 14 submitted Pre data, and 8 submitted Post data. There were significant differences between pre and post data relating to consideration of trauma-informed care, and confidence in trauma assessment and intervention skills. However, levels of significance were not met for the differences in confidence around identifying pathways of care. From analysis of the qualitative data three main themes were identified 1) Quality of care and Trauma focus, 2) Practitioner experience and 3) Veteran Experience which are explored within the discussion.ConclusionsThe use of a structured pathway improved the delivery of a trauma-informed care approach within a high intensity service for veterans, with positive changes in both practitioner and veteran experiences

Physical therapy for injuries of the temporomandibular joint

injuries of the temporomandibular joint (TMJ) pose significant challenges to patients' well-being and require comprehensive treatment strategies. Physical therapy has emerged as a vital component in the management of TMJ injuries, with its efficacy increasingly recognized in clinical practice. This review provides a thorough summarize of physical therapy interventions for TMJ injuries, focusing on their role in restoring joint function and improving patient outcomes. Additionally, this review explores emerging trends and future directions in TMJ physical therapy, including advancements in technology and novel treatment modalities. Through a synthesis of current research and clinical evidence, the review explores various physical therapy modalities, including exercises, manual therapy techniques, and patient education programs. Additionally, the review discusses the mechanisms of action underlying physical therapy interventions and their impact on TMJ mobility, pain reduction, and overall quality of life. The relevance of physical therapy in the multidisciplinary approach to TMJ injury management is emphasized, highlighting its potential to complement other treatment modalities such as pharmacotherapy and surgical interventions. Furthermore, the review addresses considerations for optimizing physical therapy protocols, including patient selection, treatment duration, and therapist expertise. Overall, this review underscores the importance of physical therapy in the comprehensive care of TMJ injuries and provides insights into its implementation for clinicians and researchers alike. Considerations for patient-centered care and shared decision-making are also addressed, recognizing the importance of individualized treatment plans tailored to patient preferences and goals. By providing a comprehensive overview of physical therapy for TMJ injuries, this review aims to inform clinicians, researchers, and policymakers about the evolving landscape of TMJ management and promote evidence-based practice for improved patient outcomes and quality of life.

Complex q-rung orthopair fuzzy Yager aggregation operators and their application to evaluate the best medical manufacturer

In contemporary healthcare systems, the selection and judicious choice of the right medical device becomes paramount consideration for accurate diagnosis, patient care, mitigate risk and cost incurred on diagnosis of disease. Moreover, medical devices are requisite indispensable tools to help healthcare professionals for effective diagnosis, selection of the right treatment amongst different options, and continuous monitoring of the patient. Thus, to select the best manufacturing company is as equally important to achieve the desired goals. This paper presents a decision making algorithm based on fuzzy theory that helps the decision maker in selecting the most suitable worldwide medical device manufacturer. Fuzzy theory is extensively used in managing databases and analyzing data to summarize information and draw meaningful conclusions. This paper utilizes the aggregation operators within the context of the complex q-rung orthopair fuzzy environment by utilizing Yager t-norm and t-conorm operations. Some aggregation operators are applied, namely, complex q-rung orthopair fuzzy Yager weighted geometric operator, complex q-rung orthopair fuzzy Yager ordered weighted geometric operator, complex q-rung orthopair fuzzy Yager weighted averaging operator and complex q-rung orthopair fuzzy Yager ordered weighted averaging operator. Additionally, the notable properties of these operators are proved. These aggregation operators are generated specifically for multi-criteria decision-making. Decision making algorithm is used to choose the most relevant medical device manufacturer (alternative) to validate its efficacy. The results demonstrate the versatility of parameters, adaptability to multi-criteria decision making, and efficiency of the proposed aggregation operators and algorithm. Test with specific criteria is also conducted to verify the legality and validity of the decision making algorithm. At last, the acquired results underwent a comparative analysis against various established methodologies, confirming the method’s capacity to produce precise and accurate outcomes.

Considerations of gender-affirming care for transgender and gender-diverse youth.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Recent Trends in the Management of Acne Vulgaris: A Review Focusing on Clinical Studies in the Last Decade.

Acne vulgaris is a prevalent chronic inflammatory skin condition with significant implications for quality of life, particularly among adolescents and young adults. Recent advancements in understanding its pathophysiology and developing novel therapeutic modalities have reshaped the landscape of acne management. This review provides an overview of recent trends in acne management, focusing on clinical studies conducted in the past decade. Key findings include insights into acne pathogenesis, emerging treatment modalities, comparative effectiveness of traditional and emerging therapies, and considerations for patient-centered care. The review underscores the importance of staying updated with recent clinical studies to provide evidence-based care and optimize patient treatment outcomes. Moreover, it highlights the need for continued research efforts to develop personalized treatment approaches, explore combination therapies, and address the psychosocial impact of acne. Collaborative endeavors between clinicians and researchers are essential to advance the field of acne management and improve patient outcomes.

Beyond the brain: General intensive care considerations in pediatric neurocritical care

Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients.The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.

Living with Dysphagia: A Survey Exploring the Experiences of Adults Living with Neuromuscular Disease and their Caregivers in the United Kingdom.

Dysphagia is common in adults living with neuromuscular disease (NMD). Increased life expectancy, secondary to improvements in standards of care, requires the recognition and treatment of dysphagia with an increased priority. Evidence to support the establishment of healthcare pathways is, however, lacking. The experiences of people living with NMD (pplwNMD) and their caregivers are valuable to guide targeted, value-based healthcare. To generate preliminary considerations for neuromuscular dysphagia care and future research in the United Kingdom, based on the experiences of those living with, or caring for, people with NMD. Two surveys (one for adults living with NMD and dysphagia, and a second for caregivers) were co-designed with an advisory group of people living with NMD. Surveys were electronically distributed to adults living with NMD and their caregivers between 18th May and 26th July 2020. Distribution was through UK disease registries, charity websites, newsletters, and social media. Adults living with NMD receive little information or education that they are likely to develop swallowing difficulties. Most respondents report wanting this information prior to developing these difficulties. Difficulties with swallowing food and medication are common in this group, and instrumental assessment is considered a helpful assessment tool. Both adults living with NMD and caregivers want earlier access to neuromuscular swallowing specialists and training in how best to manage their difficulties. Improvement is needed in the dysphagia healthcare pathway for adults living with NMD to help mitigate any profound physical and psychological consequences that may be caused by dysphagia. Education about swallowing difficulties and early referral to a neuromuscular swallowing specialist are important to pplwNMD and their caregivers. Further research is required to better understand the experiences of pplwNMD and their caregivers to inform the development of dysphagia healthcare pathways.

Consensus guidelines for the management of posterior fossa tumour for low- and middle-income countries.

The posterior fossa is a limited compartment therefore lesions compressing its structures can result in devastating outcomes. It can cause significant neurological deficit due to mass effect on critical structures and hydrocephalus. Due to the nature of the infratentorial region, urgent surgical intervention is often the first-line option. Surgical neuro-oncologists guide patients and caregivers through the course of this disease and to inform them about the various options for management and long-term outcome optimisation. There is currently conflicting data; however, institutional experiences can guide us towards achieving improvements in surgical outcomes and quality of life. Advances in molecular classifications coupled with highdose radiation treatment improve our capacity for improving overall survival in these patients. Common childhood tumours are ependymomas, medulloblastomas, and juvenile pilocytic astrocytomas, while adults often present with metastases, and less commonly, cerebellar haemangioblastomas and gliomas. This paper outlines management strategies with consideration for multidisciplinary care and resourcelimited settings.

Pain Research and Treatment: Policy Implications

Pain is a subjective experience for which we lack a thorough mechanistic understanding. While it has often been considered a secondary symptom of a disease, research has revealed that chronic pain can be recognized as a disease of its own. Preclinical studies often use animal models to understanding the pathology and test potential therapies with clinical trials of novel analgesics often showing underwhelming results. From a clinician's perspective, pain can be challenging to treat without incurring undesirable drug effects. Pain research, diagnosis, and treatment have changed dramatically over the last two decades. This has coincided with shifts in reliance on opioid-based approaches to managing pain. Here we present an overview of recent advances in preclinical research, novel approaches to diagnosis and treatment, along with considerations for animal care. Collectively, this report may provide a guide on which to base relevant policy changes that would meet the demands of societal need and satisfy the need for scientific evidence.