Care Literature Research Articles

Conjoined twins: an obstetrician's guide to prenatal care and delivery management.

Obstetricians infrequently encounter conjoined twins. Much of the clinical care literature focuses on postnatal management from a neonatology and pediatric surgery perspective; guidance on obstetrical management is limited. We outline steps for prenatal evaluation, obstetrical care, and delivery planning. Experiences with two cases of conjoined twins. We identified several points throughout the planning, delivery, and postnatal process that are important to highlight for optimizing clinical outcome, patient safety, and parental satisfaction. After diagnosis, patients should be referred to a center experienced in the management of conjoined twins. Specialists in fields including maternal fetal medicine, pediatric surgery, neonatology, and radiology play a vital role in the management of these patients. Early referral allows for timely family counseling and decision-making. Prenatal evaluation beyond the first trimester should include a detailed ultrasound, fetal echocardiogram, and fetal MRI. 3D printed life-sized models can improve delivery planning and patient understanding.

A Primer on Mast Cell Activation Disease for the Nurse Practitioner

The primary care literature lacks information on mast cell activation disease (MCAD) and, more specifically, mast cell activation syndrome, yet it affects approximately 17% of the population. Because many providers remain unaware of MCAD, this article provides a primer on mast cell diseases, including triggers, signs and symptoms, diagnosis, treatment, and resources for patients and providers. Primary care nurse practitioners are uniquely positioned and qualified to identify patients with multiple, diffuse complaints and chronic, multisystem symptoms—the hallmark of MCAD—and refer them for further diagnosis and treatment to reduce debilitating symptoms.

Observation and Institutional Ethnography: Helping Us to See Better.

Observation is a staple data collection method, which is used in many qualitative approaches, including both traditional and institutional ethnographies. While observation is one of the most used data collection methods in traditional ethnography, less is written about its use by institutional ethnographers. Institutional ethnography is an approach to social research where the aim is to explicate how peoples’ every activities are coordinated or ruled by different institutions. In this article we explore uses of observation as a data collection method, focusing on its use in institutional ethnography. We use examples from the health care literature to show how observation can be beneficial and help institutional ethnographers see better.

Book Review: Cohn, S.L. (Ed.). Decision Making in Perioperative Medicine: Clinical Pearls. (New York: McGraw-Hill), 2021. ISBN: 978-1-260-46810-6

Cohn’s work fills a void in the perioperative care literature by providing a concise, comprehensive, practical, and authoritative guide to the medical management of common periprocedural issues and scenarios [...]

The Use of Telemedicine to Support Interventional Pain Care: Case Series and Commentary.

Incorporating indicated interventions in a multimodal approach to manage musculoskeletal pain has become standard of care. For example, in patients with radicular pain associated with intervertebral disc herniation or lumbar spinal stenosis, epidural steroid injections (ESI) are commonly used and often improve pain and function while avoiding more invasive surgical approaches. Recently, the coronavirus disease 2019 (COVID-19) pandemic has allowed remote evaluations to mitigate COVID-19 transmission using telemedicine. In this article, we review our experience in using telemedicine for interventional pain care and current literature, providing a framework for current practice and future study. During restrictive periods of COVID-19 mitigation, patients were referred for ESI, evaluated by telemedicine, and then seen in-person for a physical exam and possible ESI. After a chart review of these patients, we found that telemedicine evaluation was successfully used to support decision making about the ESI. The majority of patients referred received an ESI. During the interval between telemedicine evaluation and ESI, there was no evidence of progression of disease or neurologic deterioration. There were no emergency room visits due to pain complaints. In our literature review, similar case series supported the use of telemedicine in planning and supporting procedural care in several clinical specialties, including interventional pain management. Future research in larger cohorts will help rigorously evaluate safety and query satisfaction for both patients and providers. In conclusion, we suggest that using telemedicine to support procedural care requires more research but shows promise in increasing access to interventional pain care.The use of telemedicine has recently seen a sharp increase in frequency due to the ongoing global COVID-19 pandemic. According to the World Health Organization, telemedicine represents “healing at a distance”1 . They define telemedicine as “the delivery of healthcare services…by health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries.” Telemedicine has become an important and effective option for providing patient care. However, the use of telemedicine in the context of procedural therapies for pain management is new and rapidly evolving. In this commentary, we aimed to review literature and share our experience in integrating telemedicine in procedural care.

Differences in End-Customer Power Prices Across the EU – Reasons and Challenges for the Future

Abstract Many years have passed since the first liberalization processes in the electricity sectors the in European Union that were performed in order to establish a single market for electricity. In practice, convergence between neighbouring market areas was established mainly between the Member States in Central-Western Europe, while other countries have allowed for only limited levels of competition. As a consequence, many market areas remain illiquid and consumers pay relatively higher prices for the energy they consume. The final bill is further increased through financing the increasingly ambitious climate agenda, gradually leading to social opposition against ever-growing prices. The aim of this article is to provide examples of differences in market functioning in Member States, leading to discrepancies in average energy costs for end consumers. The consequences of different levels of market concentration, infrastructure investments and renewable generation subsidization are analysed using publicly available statistics. Careful literature review is also performed before the conclusions are presented.

Rural health cancer care: A literature review.

e18500 Background: A recent review of the medical literature of rural health cancer care delivery has not been published. We conducted a preliminary review of the last twenty years of rural health cancer care delivery literature utilizing medical subject headings (MeSH) within the PubMed NCBI) database. Methods: Using PubMed MeSH Major Topic terms “rural population” and “cancer” we identified publications published from 2000 to 2020. We searched PubMed for publications that included the major topic MeSH terms “rural population” and “cancer”. We individually reviewed articles, confirmed the focus of the article, and subcategorized the articles. Results: We identified 580 publications which met the search criteria, the majority were focused on the United States (266), followed by China (56), Australia (54), and India (27). Among the publications focusing on the United States, 76 involved Appalachian States. Kentucky (18) and Georgia (10) were the states most frequently represented. Malignancies most commonly represented were: breast cancer (148), uterine/cervical (84), and colorectal cancers (68). The journals which published the most rural health cancer care delivery were The Journal of Rural Health (42), Asian Pacific Journal of Cancer Prevention (20), Cancer (14), Rural and Remote Health (13), Journal of Cancer Education (13), Australian Journal of Rural Health (12). Conclusions: The rural health cancer care literature in the last two decades focuses primarily on the United States, China, Australia, and India. Within the United States, the research focus is Appalachia. The majority of articles focus on breast cancer, uterine/cervical, and colorectal cancers. The journal which published the majority of rural health cancer care articles was the Journal of Rural Health.

Cultural Considerations in Palliative Care Provision: A Scoping Review of Canadian Literature.

Background: Palliative care, a division of health care that provides treatment to patients facing terminal or incurable illness, prioritizes maintaining quality of life for the patients it serves. Factors that influence quality of life are highly individualized, encompassing social, economic, or cultural determinants of health. In particular, cultural determinants remain an understudied element of palliative care.Objectives: The purpose of this article is to identify key concepts and issues arising from offering culturally relevant palliative care by reviewing how the concept of culture has been discussed in Canadian palliative care literature.Design: A scoping review of medical databases was conducted to identify recent Canadian literature connecting culture and palliative care provision. This review yielded 21 relevant results from the past 10 years.Results: Ideas frequently mentioned in Canadian palliative care literature include cultural competency in health care providers, cultural sensitivity of treatment options, and cultural accessibility of available services. Issues that arose from the literature included differing ideas of the meanings of life and death, visibility of cultural minority groups, spiritual care needs, desire to involve friends and family in care, and misunderstandings of language and communication styles.Conclusion: The results of this review provide a starting point from which health care providers can begin lending attention to cultural determinants of health, thus improving palliative care services for diverse populations.

Development of research methods curriculum for an integrated care fellowship

ObjectiveTo describe the design and delivery of a curriculum in research methods for clinical fellows in integrated care. MethodTo design the curriculum, a standard curriculum development approach was applied through an iterative improvement process with input from researchers, clinical educators, and the first cohort of fellows. The curriculum has three central goals: (1) develop fellows' capacity to interpret the integrated care literature and apply findings in practice; (2) develop fellows' capacity for conducting quality improvement programs informed by knowledge of clinical research methods; and (3) enhance workforce capacity for practice-based research partnerships by increasing research understanding among clinical providers. A variety of educational strategies were employed to introduce each research method and apply these to the integrated care literature. ResultsA description, rationale, and resources for each content domain is presented. The curriculum was delivered to two cohorts of fellows. Evaluation data supports the curriculum's relevance and quality. ConclusionsA rigorous development process yielded a brief research curriculum targeting the needs of clinical fellows in integrated care. The curriculum is well-received by fellows and adaptable for other subspecialties. It may serve as a model for other clinical training programs seeking to enhance their fellows' fluency in research methods.

Sharing meals: promising nutritional interventions for primary health care including nursing students and elderly people

BackgroundThe risk of malnutrition among elderly people is high and living alone increases the risk. As the number of older persons living alone is expected to increase due to the demographic development of an increasing older population, more knowledge about low-cost, sustainable nutritional interventions is needed. The purpose of this study was to investigate how nursing students can be a resource in the nutritional care of older persons living alone by sharing weekly meals.MethodsTwenty-three nursing students and 23 elderly people who lived alone and received home nursing care participated in the project period of 9 weeks and shared 1–2 weekly meals. Shortly after the study period, 13 students and 4 elderly persons were interviewed in individual, face-to-face, semi-structured interviews. The questions included their experiences, the perceived impact of sharing meals, and facilitators and barriers of such meal interventions. The interview material was transcribed and analyzed using qualitative content analysis as described by Graneheim and Lundman.ResultsOur study found that both nursing students and older persons expressed positive experiences from sharing meals. Nursing students with some nutritional knowledge can provide a useful, sustainable supplement to the home-care nursing staff’s limited resources and time. Improvements were found, including preparation of ready meals and the meal environment, different facilitators and barriers of the meal experience, and the possible positive impact on the elderly persons’ nutritional status, which affects meal enjoyment, appetite, food intake and weight.ConclusionDuring their practical placement in the community, nursing students can provide a useful contribution to the nutritional care of elderly persons who are at nutritional risk living alone at home by the intervention of sharing a meal together. This is a low-cost supplement to other primary health-care measures that can affect both nutritional status and adjust the appropriate care for patients. This study demonstrates a small contribution to the complex nutritional care literature based on the growing elderly population in home care and the nursing student as a valuable resource for the multidisciplinary team approach necessary to meet this challenge.

Early Tracheostomy in Morbidly Obese COVID-19 Patients: A Case Series and Discussion of Institutional Practices.

Tracheostomies are often utilized in critically ill patients on prolonged mechanical ventilation, to enhance respiratory function and facilitate ventilator weaning. Many coronavirus disease 2019 (COVID-19) patients develop serious respiratory illness requiring ventilator management. In the early phase of this pandemic, the risk of disease spread lead to the development of conservative guidelines which advocated delaying tracheostomy at least two to three weeks from intubation and, preferably, with negative COVID-19 testing. The morbidly obese patient population, however, presents a unique scenario in which early tracheostomy may be beneficial. In this article, we discuss our institution’s current practices along with clinical outcomes with reference to intensive care literature and propose that early tracheotomy in COVID-19 patients should be considered on a case by case basis.

Parturescence: A theorisation of women’s transformation through childbirth

ProblemThe potential for positive transformation through giving birth is under-acknowledged and poorly understood. Aim and methodBy drawing on theories of new feminist materialism to open up ways of thinking about childbirth and maternity care, we discuss how aspects of the process of matrescence, a woman’s ‘mother-becoming’, pertain to women’s opportunities in childbirth. We introduce the term, ‘parturescence’, as a moniker for the opportunity for ‘becoming’, and therefore transformation, offered in birth giving. Results and discussionUsing Davies’ interpretation of Bergson’s lines of descent and ascent we suggest the conditions of a woman’s parturescence (whether birth giving will result in a positive or negative transformation) is enabled by ‘with woman’ midwifery care. The intra-action between this care, and the materiality of birth – the pain and exhaustion women experience in labour and birth, results in a rematerialisation of who and what women are and the opportunity for women’s transformation. ConclusionThe development of this theory of parturescence unifies disparate aspects of maternity care and birth literature, provides insight into the potential mechanisms and conditions that impact women’s parturescence, and suggests that birth, including the challenging and destabilising parts, is not just for the production of a baby, but also a site of women’s ‘becoming’.

Precarious Care and (Dis)Connections

Abstract. Adult stakeholders who work with separated child migrants (SCMs) face a substantial challenge to their capacity or remit to care amid increasingly hostile immigration environments. This paper explores a diverse range of adult stakeholders' understandings of the care of SCMs, filling an important gap in understanding how care is conceptualized by those working in often complex and contradictory positions. Drawing on the care literature, this study focuses on 15 qualitative semistructured interviews with state and nonstate adult stakeholders in England (e.g., social work, law, police, and NGO workers). We argue that stringent immigration practices, policies, and bureaucratic and structural challenges undoubtedly present personal tensions and professional constraints for those whose role is meant to foreground “care.” Importantly, when taking into account a range of different perspectives, roles, and responsibilities across professions and sectors, our respondents were constrained in varying ways or had varying room to maneuver within their institutional contexts. Our analysis suggests that amid a hostile immigration environment, care connections with and between SCMs are treated with mistrust and are unstable over space and time. We argue that how care is conceptualized and experienced is mutually constituted by hostile policies and procedures, adult stakeholders' roles within or out-with those systems, and their personal values and perspectives. It is within this space where constraints, enablers, and resistances play out. Care is subjectively experienced, and care relationships are open to potential (dis)connection across space and time.

"Not Just Anybody Can Do It": A Qualitative Study of the Lived Experience of Inpatient Palliative Care Professionals in China's Mainland.

Background: Over the past 5 years, China has invested substantially in palliative care programs to meet the rising demand for such services. In China's mainland, most palliative care programs are embedded within an established hospital unit, but a small subset of providers practice exclusively in a stand-alone inpatient palliative care department.Objective: To explore the lived experience of professionals at an independently operating palliative care hospital department in China's mainland.Design: We used purposive sampling to select palliative care physicians and nurses. Semistructured in-depth interviews were conducted in person. Thematic analysis was used to elicit key themes that pertained to participants' lived experience.Setting/Subjects: Ten palliative care physicians and seven nurses at the palliative medicine department in the West China Fourth Hospital of Sichuan University in Chengdu, Sichuan Province, participated in the interviews.Results: Three themes related to participants' lived experience were (1) interactions with patients and families (e.g., frequent encounters with death, communication difficulties, witnessing family struggles, and developing mutually trusting relationships); (2) factors influencing their work life (e.g., supportive working environment, unmet training needs, policy restrictions, and lack of public awareness); and (3) perceived nature of work (e.g., complex and demanding, underappreciation, encroachment of work stress into personal life, deriving accomplishment from work, and personal growth).Conclusion: This study helps fill the void in the palliative care literature regarding the lived experience of inpatient palliative care professionals in China's mainland. Our findings revealed factors influencing the well-being of palliative care professionals that are meaningful to policymakers.

649 The Quality of Survey Research in Burn Care: A Systematic Review

Abstract Introduction Burn care is a relatively small field with contributions from many healthcare disciplines. Further, the practice of burn care varies considerably from center to center and between regions. Given these factors, survey studies are frequently used to better understand practice variations, establish guidelines, and direct future research questions. If survey research is poorly designed or reported, it limits the ability to form meaningful conclusions. Given the prevalence of clinician surveys published in burn care, this study aims to evaluate its quality and to determine which approaches lead to a more successful survey. Methods A systematic review was performed by two independent reviewers using PubMed, Scopus, and Web of Science databases for the dates January 1, 2000 to March 19, 2020. Articles were included if they were published in English and surveyed providers on a topic related to burn care. Surveys of patients, those that evaluated an intervention or included other research designs were excluded. Data related to survey content, methodology, and quality was extracted independently by two reviewers. Results The search identified 7351 non-duplicate citations, of which 247 underwent full text review, and 144 met inclusion criteria. The number of published surveys increased by an average of 21% annually over the study period (P< 0.001). The majority of surveys originated in the United States (40%), United Kingdom (19%) and Canada (7%) and were either national (47%) or international (37%) in scope. The most common themes were education/training/workforce (21%), resuscitation/critical care (17%) and wound care (14%). Burn surgeons/physicians (45%) were the most frequently surveyed population, but all disciplines were represented. The majority of surveys were electronic (51%) and sampled all members of a defined group (72%). Few studies reported the use of reminders (29%) or incentives (2%) to improve survey completion. In terms of quality, the majority did not report any survey development steps (71%) or survey validity/reliability (92%), and half did not include the questionnaire in the manuscript or appendix. A response rate was calculated in 82% of studies. The median (IQR) response rate of all studies was 54% (32–83). A subgroup analysis of national and international studies sent electronically to burn surgeons/physicians (N=28) had a response rate of 40% (26–50). Conclusions Survey research is increasingly published in the burn care literature and covers a range of themes and populations. Despite the limited use of reminders and incentives, survey participation is relatively high. The quality of survey reporting is generally poor, limiting the ability to apply this research into practice.

39 The Experiences of Treatment Burden Among People with Parkinson’s Disease and Their Caregivers: A Systematic Review

Abstract Introduction Treatment burden is the “workload of healthcare and its impact on patient functioning and well-being”. High treatment burden may lead to non-adherence to treatment regimens, poor health outcomes, poor quality of life and wasted healthcare resources. Treatment burden among people with Parkinson’s (PwP) and their caregivers has not been previously explored. Methods Using five electronic databases (MEDLINE, Embase, CINAHL, Scopus and PsychInfo), we conducted a systematic review of studies published since 2006 when the first National Institute for Clinical Excellence (NICE) Clinical Guideline for Parkinson’s Disease was published. This allows an understanding of the impact of current healthcare systems on treatment burden. We included qualitative and mixed-method studies with a qualitative component that reported data from PwP and/or caregivers. Quantitative studies, qualitative data from clinical trials not related to usual care and grey literature were excluded. Two reviewers independently screened articles and extracted data. Data analysis was conducted using framework analysis. Results 1757 articles were screened, and 39 included in this review. Understanding treatment burden among PwP and their caregivers was not the primary aim in any of the included studies. They described the experiences of those living at home and during hospital or care home admissions. Issues with medications (adherence to advice, effectiveness, side-effects and timing), obtaining appropriate levels of information and healthcare provision (lack of integrated care, care coordination and person-centred approach) were among factors that exacerbate treatment burden experienced by PwP and caregivers. Both reported the impact of Parkinson’s on their daily lives, physical and mental exhaustion of self-care and limitations on their role and social activities. Conclusion This review describes considerable treatment burden experienced by PwP and their caregivers and its major influences including aspects of current healthcare provision. Future research should focus on patient-centred care with service redesign to improve this treatment burden.

‘ … breaks down silos’: allied health clinicians’ perceptions of informal interprofessional interactions in the healthcare workplace

ABSTRACT Informal interprofessional interactions have gained interest in recent interprofessional care, education, health services and social sciences research literature. Some of the established benefits associated with these interactions include enhanced communication, teamwork, research translation and the provision of safer care. Limited evidence about how informal interprofessional interactions are perceived by the allied health workforce, exists. The survey conducted at a large Australian health service explored allied health clinicians’ perceptions of the benefits, challenges and enablers of informal interprofessional interactions and their recommendations to improve opportunities for these workplace interactions. Sixty-four responses were analysed descriptively (for close-ended questions) and using a framework analysis approach, informed by Bourdieu’s social space theory (for open-ended questions). Perceived benefits were aligned with three themes: teams and organisations, individual clinicians and service-users. Challenges to, and enablers of, informal interprofessional interactions were identified according to five themes: socio-cultural practices, physical environment, timing-related factors, individual and organisational factors. Participant recommendations to increase opportunities for informal interprofessional workplace interactions for allied health reflected three of the aforementioned themes: socio-cultural practices, physical environment and organisational factors. This theoretically-informed analysis may aid in the development of strategies to support these types of workplace interactions and realise the benefits identified.

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review.

Purpose of ReviewTo highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients.Recent FindingsA significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages.SummaryWith little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

COVID-19-associated meningoencephalitis: A care report and literature review.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may target the central nervous system and several neurological symptoms have been reported in patients with coronavirus disease 2019 (COVID-19). In the present study, a case of a SARS-CoV-2 complicated with meningoencephalitis was reported. Cerebrospinal fluid (CSF) analyses indicated hyperproteinorrachia but the specimen was negative for SARS-CoV-2 RNA. Furthermore, 10 published articles reporting on patients with COVID-19-associated meningitis/encephalitis were reviewed. Patients diagnosed with COVID-19-associated meningitis/encephalitis had diverse clinical neurological manifestations, including consciousness disturbance, epileptic attacks, psychotic syndrome and meningeal irritation signs. CSF tests revealed elevated protein, lymphocytes and cytokines. SARS-CoV-2 may be detected in the CSF of certain cases. Neuroimaging findings included hyperintense signal changes in the white matter and enhancement of meninges on brain MRI. Certain patients responded well to corticosteroid therapy and had a favorable prognosis, while elderly patients tended to have poor outcomes due to multiple organ dysfunction.

1136 The FAST exam in obstetrics: a feasibility study

The Focused Assessment with Sonography for Trauma (FAST) exam, is a point of care ultrasound evaluation used routinely in surgical and trauma evaluation of critically ill patients to assess intrabdominal free fluid. It is a cost effective, noninvasive approach with no radiation exposure, which allows for rapid decision making in surgical intervention. Although extensively evaluated in the trauma and critical care literature, this study has never been evaluated in an obstetric population. Our objective was to create an ultrasound training protocol and evaluate the feasibility of this study during pregnancy. This is a prospective, observational study completed in large academic center. Health care providers (sonographers and physicians) underwent an ultrasound training protocol involving a live webinar and on-site supervision to obtain the four standard FAST exam views (the right upper quadrant, left upper quadrant, subcostal cardiac, and pelvis). Patients were enrolled after their routine obstetric ultrasound evaluation and additional images for the FAST exam were completed. The images were then reviewed for quality by a blinded physician subspecialist in clinician performed ultrasound and critical care echocardiography. 64 ultrasound studies were completed each evaluating standard FAST exam views. 62/64 (96.8%) of exams had adequate visualization of all windows. Fisher exact test was completed and no significant differences in visualization across gestational age between early pregnancy (24 weeks) , or BMI were noted (P<0.05). The FAST exam is a feasible study among pregnant women, it is not affected by gestational age or BMI. Training of obstetric providers with a web-based ultrasound protocol and quality review of images demonstrates the ability of clinicians familiar with obstetric ultrasound the ability to complete the FAST exam successfully. This is a novel study, suggesting the FAST exam may serve as a useful clinical adjunct during assessment of critically ill obstetric patients.