Selection Care Research Articles

OUT OF POCKET EXPENDITURE ON DELIVERY AND POSTNATAL CARE IN PUBLIC AND PRIVATE HOSPITALS

Abstract 
 Background: Pakistan is a developing country of South Asia and currently facing many challenges and public health especially maternal health is one of the emerging issues. There is limited empirical evidence on the out of pocket expenditure (OOPE) on selection of public and private healthcare facility. This area was overlooked in the research and the current study has tried to investigate the impact of OOPE on public and private hospital selection for delivery and postnatal care.
 Methods: survey approach was used. Primary data was collected from the Rajanpur district of Punjab Pakistan. Descriptive statistics and backward binary logistic regression were used. Non-probability convenience sampling technique was used for selection of sample size. Total 368 completed questionnaires were used in the analysis.
 Findings/Results: results revealed that Results also revealed that mothers with high in age, education were found significant and their spouse with government jobs, self employed prefer to go to public sector hospitals for delivery. Those respondents having income between 10 thousand PKR to 20 thousand PKR likely to go to public sector facility and mothers having more children such as 3-4 or above like to go public hospitals for delivery. Moreover distance from home to hospital and transportation charges and OOPE also play significant role in selection of healthcare facility. On the other hand age of mother, transportation and distance from home to hospital does not play any significant role for postnatal care while remaining factors such as education of mother, occupation of mother and household head, family income, number of children and out of pocket medical expenses plays significant role in selection of hospital for postnatal care.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting. Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes. Population-based descriptive cohort study. Alberta Kidney Care South. Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019. Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations. We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios. Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting. The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics. Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events. Not applicable.

Expert System of Facial Skin Type Diagnosis and Skincare Recommendation Based on Certainty Factor

Facial treatment is an important need for everyone because the first sight of meeting someone is to see their face. Generally, facial skin type is just normal skin. However, several factors such as the environment, air, food, facial hygiene, and so on can affect the type of human facial skin. In this experiment, there were 5 types of facial skin, namely normal skin, dry skin, oily skin, combination skin, and sensitive skin. With the existence of various skin types, it makes some people confused in determining the type of facial skin. This also affects the selection of skincare or facial care according to the indications of each facial skin. Therefore an expert system was created to diagnose facial skin types. An expert system is a man-made system that is used to solve problems like an expert with knowledge from human to computer, although it does not give 100% absolute results, but expert systems are still helpful.

419 Filling the Gap in Psoriasis Care: A Qualitative Study About Patients’ Needs & Expectations and Exploring the Role of a Psoriasis Nurse Specialist

Psoriasis is a chronic skin disease with large impact on quality of life and comorbidities such as depression and cardio-vascular disease. A holistic approach of this disease, for which there is no cure, is needed. A nurse specialist (NS) could play a valuable role in psoriasis care but not much is known about psoriasis patients their needs and expectations towards such NS. We aimed to explore psoriasis patients their needs and expectations in care, and more specifically towards NS. Data was collected through semi-structured interviews with as topics experiences related to care and treatment selection.

Distribution of Viral Respiratory Infections during the COVID-19 Pandemic Using the FilmArray Respiratory Panel.

This study was conducted to evaluate the distribution of respiratory viral pathogens in the emergency department during the coronavirus disease 2019 (COVID-19) pandemic. Between May 2020 and September 2022, patients aged between 0.1 and 98 years arrived at the emergency department of Asia University Hospital, and samples from nasopharyngeal swabs were tested by the FilmArrayTM Respiratory Panel (RP). SARS-CoV-2 positivity was subsequently retested by the cobas Liat system. There were 804 patients for whom the FilmArrayTM RP was tested, and 225 (27.9%) of them had positive results for respiratory viruses. Rhinovirus/enterovirus was the most commonly detected pathogen, with 170 (61.8%) cases, followed by adenovirus with 38 (13.8%), SARS-CoV-2 with 16 (5.8%) cases, and coronavirus 229E, with 16 (5.8%) cases. SARS-CoV-2 PCR results were positive in 16 (5.8%) cases, and there were two coinfections of SARS-CoV-2 with adenovirus and rhinovirus/enterovirus. A total of 43 (5.3%) patients were coinfected; the most coinfection was adenovirus plus rhinovirus/enterovirus, which was detectable in 18 (41.9%) cases. No atypical pathogens were found in this study. Intriguingly, our results showed that there was prefect agreement between the detection of SARS-CoV-2 conducted with the cobas Liat SARS-CoV-2 and influenza A/B nucleic acid test and the FilmArrayTM RP. Therefore, the FilmArrayTM RP assay is a reliable and feasible method for the detection of SARS-CoV-2. In summary, FilmArrayTM RP significantly broadens our capability to detect multiple respiratory infections due to viruses and atypical bacteria. It provides a prompt evaluation of pathogens to enhance patient care and clinical selection strategies in emergency departments during the COVID-19 pandemic.

Pattern of Radiotherapy Treatment for Prostate Cancer (PCa) Patients: Analysis of a Hospital Based Registry

<h3>Purpose/Objective(s)</h3> Prostate Cancer (PCa) is the most common cancer among males and is the second leading cause of cancer related mortality. Definitive radiation therapy (RT) plays an important role in curative intent treatment for localized prostate cancer. RT can be delivered with various radiation techniques depending on availability of resources and patient-specific criteria. The aim of this study was to compare the utilization of various RT techniques using a large, national hospital-based registry. <h3>Materials/Methods</h3> We analyzed an extensive data set of N0, M0, non-surgical PCa patients diagnosed between 2004 and 2015 using National Cancer Database (NCDB). Patients were grouped into six categories based on RT modality: (<b>1</b>) IMRT with brachytherapy (BT) boost (n=12,734), (<b>2</b>) IMRT only (n=106,246), (<b>3</b>) Proton therapy (n=4,561), (<b>4</b>) SBRT (n=7,533), (<b>5</b>) LDR BT (n=45,452), and (<b>6</b>) HDR BT (n=23,400). Patients were also stratified according to the NCCN guidelines: low-risk (c_stage T1-T2a, Gleason Score (GS) ≤ 6, Prostate-Specific Antigen (PSA) < 10), intermediate-risk (c_stage T2b or T2c, GS of 7, PSA of 10-20), and high-risk (c_stage T3-T4, GS of 8-10, PSA > 20). Overall survival (OS) probability was determined using a Kaplan-Meier estimator. Univariate and multivariate analyses of patient characteristics were performed by risk group for the six treatment modalities. <h3>Results</h3> The most commonly used treatment modality for PCa patients was IMRT (53.1%) across the risk groups. In the low-risk group, IMRT and LDR BT were utilized in a similar proportion (35.0%). A steady increase of SBRT utilization was observed (from 0% in 2004 to over 10% in 2015 for low- and intermediate-risk patients), while HDR BT usage declined markedly. Highest OS probability was observed for the proton therapy group, while SBRT, LDR BT, HDR BT, and IMRT+BT had similar survival probabilities. IMRT was associated with the lowest OS. Higher median incomes (HR=0.63, p<0.01), treatment at academic/research facilities (HR=0.83, p<0.01), and increased distance of residence from treatment facility (HR=0.94, p<0.01) were some factors with strongest association to increased overall survival. <h3>Conclusion</h3> This study revealed that IMRT was the most common RT modality for PCa patients over the study period, with a steady increase in SBRT technique and decline in BT. The rate of utilization for each RT modality was not representative of its corresponding median OS in the studied population. The association of improved OS with proton therapy, higher median income, and increased distance from treatment facility all suggest that health care disparities and selection biases are largely responsible for the differences observed, both by the clinicians' offering of select modalities and the patients' access to pursue certain therapy. Future management of PCa patients via radiotherapy modalities would likely benefit from randomized clinical trials and longer observation periods.

Incidence and risk factors for graft failure in the modern era of cord blood transplantation.

Graft failure (GF) after cord blood transplant (CBT) has decreased with improved supportive care and cord selection strategies. We aimed to evaluate cord blood selection and factors associated with retransplantation on the incidence of GF, determine risk factors for GF including host antibodies to Kell antigen and evaluate survival after GF. We retrospectively reviewed 84 patients who underwent CBT at the University of Oklahoma between 2000 and 2016 and compared outcomes in patients with/without engraftment by Day 28. The nonengraftment cohort was further divided into patients who underwent retransplantation. Kaplan-Meier curves with log-rank tests were calculated to assess the association between mortality and engraftment. Engraftment following CBT was high at 81%, with 52% engrafting by Day 28 and an additional 29% engrafting by a median of 36 days. Retransplantation led to 88% engraftment at a median of 53 days. Overall, 75% of the 40 patients who did not engraft by Day 28 died. Female sex and total nucleated cell count < 3.5/kg were significantly associated with lack of engraftment and higher mortality. Antibodies to Kell fetal antigen were not identified. Retransplantation by Day 28 for primary GF conferred a survival advantage. This study demonstrates that failure to engraft by 28 days was associated with increased mortality, and risk was mitigated with early retransplantation. Female sex and low total cell dose were associated with increased mortality. Early identification of GF coupled with early retransplantation can reduce mortality in CBT.

10.1 The Importance of Engaging With Patients in Outcome Selection for Meaningful Measurement-Based Care

A key element of designing a meaningful approach to measurement-based care (MBC) involves thoughtful outcome selection. As part of an international, multistage project to develop a core outcome set (COS) in adolescent (aged 12 to 18 years) MDD clinical trials, we set out to identify what outcomes had been selected by researchers to measure in the literature to date, and to understand what outcomes patients considered important to select and measure. A COS is a minimal set of outcomes that should be measured in research, without precluding the inclusion of other outcomes.

The Risk Factors and Incidence of Perineal Tears among Pregnant Women

Aim: To determine the risk factors and prevalence of perineal tear in low-risk pregnant females. Study Design: A retrospective cross-sectional study. Place and Duration: In the Obstetrics and Gynecology department of Khawaja Muhammad Safdar Medical College, Allama Iqbal Memorial Teaching Hospital Sialkot for one-year duration from January 2020 to December 2020. Methods: The females with perineal tear after birth included in this study. A total of 400 females were selected for this study. Results are articulated as adjusted odds ratio (OR) and &lt;0.05 of P value is considered significant. Results: 400 total females had singleton vaginal delivery and perineal tears were noticed in 140 females. The episiotomy frequency for the total of 1st and 2nd degree, and 3rd and 4th degree (OASI) were 16.3%, 25%, and 1.5%, correspondingly. The perineal tear risk-factors are young mothers (teenagers OR = 5.6, 21-25 years OR = 4.3), primiparous women (OR = 12.6), gestational age less than 32 weeks OR = 0.175), received antenatal care (OR = 0.42), correspondingly. Primiparous females were 12.4 times more probable to have an episiotomy (OR = 12.4, 95% CI, 1.48-104.8, p = 0.02). A birth weight between 2.5-3.0 kgs and less than 2.5 kg (OR = 0.012 and 0.084, respectively) protects against Obstetric Anal Sphincter Injury. Conclusions: The perineal injuries risk factors are comparable to those formerly described in other researches. There is an urgent need to train the gynae staff and doctors in proper selection for episiotomy and better perineal care in order to improve obstetric services in the Gynecology department. Identifying those at danger can decrease obstetric perineal injuries. Keywords: Low risk pregnancy, episiotomy, low-risk pregnancy and Obstetric Anal Sphincter Injury.

Relationship between items of DMIST and healing of diabetic foot ulcers.

A monitoring tool for the wound-healing process of diabetic foot ulcers (DFUs) was developed. It comprises seven domains, namely, depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining. It was named "DMIST" based on the initials of its domains. Although DMIST is useful for assessing wound-healing processes, the monitoring items related to wound healing remain unclear, thereby making the selection of optimal care based on the assessment difficult. We identified the relationship between the DMIST items and wound healing. This study was a secondary analysis of five previous investigations and was conducted using DMIST based on the diabetic foot ulcer assessment scale score and DFU images. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) after simultaneously controlling for potential confounders. The examined DFU healing status revealed that some DFUs healed at 4 weeks from baseline, whereas some DFUs did not. Variables considered in the models were the scores of each DMIST domain. The study population comprised 146 Indonesian patients and 33 Japanese patients. Depth, maceration, and size were associated with DFU healing at 4 weeks from baseline [depth: OR=0.317 (95% CI: 0.145-0.693, P=0.004); maceration: OR=0.445 (95% CI: 0.221-0.896, P=0.023); size: OR=0.623 (95% CI: 0.451-0.862, P=0.004)]. Our findings suggest that appropriate management of maceration promotes DFU healing.

Computed tomography of traumatic brain injury in infants and young children (a literature review)

Objective . To analyze recent studies related to the use of computed tomography in traumatic brain injury in young children. Results . Traumatic brain injury (TBI) is one of the most common causes of death and disability in children. Pediatric TBI has a number of characteristics different of adults. This is due to age-related anatomical and physiological differences depending on patient's physical condition and on problems with his/her neurological assessment. Young children demonstrate specific pathological reactions to TBI with clear concomitant neurological manifestations. The authors present an important information on current aspects of CT application for all types of isolated blunt TBI in children aged from birth to 3 years with consideration of age-appropriate characteristics and emergency condition. Although TBI mechanisms are similar in young children and adults, visual manifestations of head injury in children have their own specific features due to the developing brain and cranial vault. Radiologist's primary role is to identify and characterize the type and severity of head injury so as to assist the correct management of the patient. Using the information obtained from CT examination and knowing TBI mechanisms in infants and young children, a radiologist can play a key role both in diagnostics and in selection of effective care, thus improving clinical outcomes. Conclusion . Head CT with multifaceted and 3D reconstructions has now replaced X-ray examination of the skull in suspected TBI and has become the most important diagnostic technique in patients with TBI at emergency settings. Radiographs do not provide with additional diagnostic information and may be excluded from the examination, if CT with 3D reconstruction are planned to perform or has already been performed.

Risk factors for peripheral intravascular catheter-related phlebitis in critically ill patients: analysis of 3429 catheters from 23 Japanese intensive care units

BackgroundPhlebitis is an important complication occurring in patients with peripheral intravascular catheters (PIVCs). The risk factors for phlebitis in the intensive care unit (ICU) was examined.MethodsA secondary analysis of a prospective multicenter cohort study was conducted, involving 23 ICUs in Japan—the AMOR–VENUS study. Consecutive patients aged ≥ 18 years admitted to the ICU with newly inserted PIVCs after ICU admission were enrolled. Characteristics of the ICU, patients, PIVCs, and the drugs administered via PIVCs were recorded. A marginal Cox regression model was used to identify the risk factors associated with phlebitis.ResultsA total of 2741 consecutive patients from 23 ICUs were reviewed for eligibility, resulting in 1359 patients and 3429 PIVCs being included in the analysis population. The median dwell time was 46.2 h (95% confidence interval [CI], 21.3–82.9). Phlebitis occurred in 9.1% (95% CI, 8.2–10.1%) of catheters (3.5 cases/100 catheter days). The multivariate analysis revealed that the only factors that increased the risk of developing phlebitis were drugs administered intravenously. This study included 26 drugs, and 4 were associated with increased phlebitis: nicardipine (HR, 1.85; 95% CI, 1.29–2.66), noradrenaline (HR, 2.42; 95% CI, 1.40–4.20), amiodarone (HR, 3.67; 95% CI, 1.75–7.71) and levetiracetam (HR, 5.65; 95% CI, 2.80–11.4). Alternatively, factors significantly associated with a reduced risk of phlebitis were: standardized drug administration measures in the ICU (HR, 0.35; 95% CI, 0.17–0.76), 30≤ BMI (HR, 0.43; 95% CI, 0.20–0.95), catheter inserted by a doctor as nurse reference (HR, 0.55; 95% CI, 0.32–0.94), and upper arm insertion site as forearm reference (HR, 0.52; 95% CI, 0.32–0.85). The nitroglycerin was associated with a reduced phlebitis risk (HR, 0.22; 95% CI, 0.05–0.92).ConclusionVarious factors are involved in the development of phlebitis caused by PIVCs in critically ill patients, including institutional, patient, catheter, and drug-induced factors, indicating the need for appropriate device selection or models of care in the ICU.Trial registration: UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019, July 1, 2017).

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

An advanced transparent hydropolymer wound dressing for undisturbed post-op management of surgical wounds following hip and knee replacement: A prospective observational series.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are standardised surgical procedures for patients with complex comorbidities. The enhanced recovery after surgery (ERAS) protocol has shown reduced lengths of hospital stay and reduced postoperative complications. Currently, there is a paucity of recommendations in regards to dressing selection for postoperative wound care within the ERAS protocol. The aim of this study was to investigate the usefulness of a transparent hydropolymer wound dressing in suit for 14 days in 20 orthopaedic patients following hip or knee arthroplasty under the ERAS protocol. The majority of participants (90%) had a wear time of 14 days without the need for dressing removal. Clinicians rated the dressing very easy to apply with very good visibility of the incision line (100%). All participants reported the dressing to be ‘very comfortable’ (95%, n = 19) or ‘comfortable’ (5%, n = 1). Overall, the transparent hydropolymer dressing provided sufficient incision site visibility, reducing the need for dressing changes. To the best of our knowledge, this is the first study to show that the use of a transparent hydropolymer dressing in situ for 14 days to allow undisturbed wound healing.

Does the incremental shuttle walk test predict the development of a hospital acquired pneumonia in patients undergoing elective oesophagectomy: A service evaluation

Introduction Post-operative morbidity following oesophagectomy is high, with pulmonary complications, including hospital acquired pneumonia (HAP), the most commonly reported. Functional assessment to determine fitness for surgery is important to provide an individualised risk profile, helping to guide collaborative decision making around selection for surgery and post-operative care. The incremental shuttle walk test (ISWT) can be used to objectively measure functional capacity. Previous studies have demonstrated walking &lt;350m on the ISWT is associated with significantly higher 30 day and 3-year mortality. The aim of this service evaluation was to assess if walking &lt;350m on the ISWT correlated with the development of HAP. Methods Consecutive patients with oesophagogastric cancer listed for an elective oesophagectomy at a large U.K. tertiary hospital between December 2017 and February 2020 were included in analysis. All patients completed the ISWT at pre assessment clinic approximately 1 week prior to surgery. Primary outcome was incidence of HAP. Secondary outcomes included re-intubation rates, intensive care unit (ICU) re-admissions, ICU and hospital length of stay, and 30, 90 day and 12 month mortality. Results 121 patients completed the ISWT and were included in analysis of which 25 (21%) walked &lt;350m. Those walking &lt;350m had significantly higher rates of hospital acquired pneumonia (44% v. 11%, p = 0.0003) and spent significantly longer on ICU (5 v. 3 days, p = 0.041). Poor performance on ISWT had no significant effect on either 30, 90 day or 12 month mortality. Conclusion Walking less than 350 metres on the ISWT pre operatively was associated with a significant increase in the likelihood of developing HAP and longer stays in the ICU. The ISWT may therefore be a useful tool to help manage patient and clinician expectations, guide clinical decision making related to post-operative care, for example, high dependency unit vs ICU and direct post-operative resources like physiotherapy to patients most at risk.

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Choosing Non-Malignant Hematologic Care Wisely: An Educational Pilot Study for Internal Medicine Residents

Introduction: Choosing Wisely ® (CW ®)is an initiative of the American Board of Internal Medicine Foundation created to guide the selection of care that is 1) supported by evidence, 2) not duplicative, 3) free from harm, and 4) truly necessary. Between 2013-14, the American Society of Hematology (ASH) published 10 recommendations in accordance with CW ® principles relevant to hematologic care. Previous studies have demonstrated that clinical exposure to non-malignant hematology (NMH) improves trainee understanding of evidence-based, cost effective care as outlined by ASH CW ®. However, dedicated clinical rotations in NMH for internal medicine (IM) residents are not consistently available. Therefore, we created a condensed educational curricular experience using a small group, case-based structure designed to teach the fundamentals of ASH CW ® in NMH to first year IM residents. With a pilot of 6 sessions, we investigated resident baseline knowledge, evaluated the curricular session, and assessed knowledge retention.Methods: The educational intervention focused on 3 content areas in ASH CW ®: venous thromboembolism (VTE), heparin-induced thrombocytopenia (HIT), and sickle cell disease (SCD) (Table 1). Participants included 21 first year IM residents at a large academic medical center. A 1-hour small group teaching session was scheduled monthly as an assigned didactic for the 2020-21 academic year. A total of 6 sessions were provided, and each session had 2-4 residents assigned. The first 4 sessions were in-person and the final 2 were virtual due to the COVID-19 pandemic. The first author was the instructor at all sessions.To assess baseline knowledge of the 3 content areas, participants completed an online assessment with 5 case-based multiple-choice questions at the beginning of the session. The instructor then guided participants to again complete the questionnaire together, now using internet access via a personal computer and a recommended list of online resources, including ASH Clinical Practice Guidelines and Pocket Guides. The instructor then led discussion on how each correct answer or guideline recommendation achieves the 4 CW ® principles. At the conclusion of the session, participants completed an online survey to evaluate the educational intervention using a modified Likert scale. To assess knowledge retention, participants received the original online multiple-choice assessment by email 3 months later.Results: All participants (21/21, 100%) completed the baseline knowledge assessment. The average number of questions correct out of 5 total was 3.3 (67%), with a range of correct answers from 1 to 5. Table 2 includes the content area of each question and the number of correct responses. The question with the lowest total correct (9/21, 43%) addressed the use of transfusion in an uncomplicated pain crisis in SCD.Seventeen participants (81%) completed the curricular evaluation. All respondents (17/17, 100%) either agreed or strongly agreed 1) that the session filled a gap in their NMH training and 2) that they learned something that would change their clinical practice. Only 1 participant (5%) reported completing a rotation in NMH prior to the session.Six participants (29%) completed the repeat knowledge assessment at 3 months. All respondents (100%) achieved a perfect score on the multiple choice questions. When asked if the knowledge gained had influenced their clinical practice, 3 (50%) strongly agreed, 2 (33%) agreed, 1 (17%) was neutral, and none disagreed or strongly disagreed.Conclusion: Our results demonstrate a successful educational pilot to improve the knowledge of ASH CW ® initiatives in NMH for first year IM residents using small group interactive case-based learning. Participants were overwhelmingly receptive to this intervention, expressed high satisfaction and confirmed that the session positively influenced their clinical practice. Although participation in the repeat assessment of knowledge was limited, those that did participate demonstrated high knowledge retention. We intend to expand this pilot initiative by providing the educational session for all incoming IM residents at our institution. We then plan to assess its impact on clinical practice (i.e. use of transfusion in SCD, use of thrombophilia testing, documentation of 4Ts score calculation) to apply the principles of ASH CW ® for improved patient care. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study.

The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.

Partial paternity does not always select for female-biased care.

The theoretical literature predicts that parentage differences between the sexes, due to females mating with multiple males, select males to provide less parental care and females to care more for the offspring. We formulate simple evolutionary games to question the generality of this prediction. We find that the relationship between paternal care and fitness gained from extra-pair matings is important. A trade-off between these two quantities is required for partial paternity and complete maternity to bias the evolutionary stable strategy (ESS) toward more female care. We argue that this trade-off has been implicitly or explicitly assumed in most previous theories. However, if there is no trade-off between paternal care and extra-pair matings, parentage differences do not influence the ESS sex roles. Moreover, it is also possible for these two quantities to have a positive relationship, in which case we predict selection for male care is possible. We support these predictions using agent-based simulations. We also consider the possibility that caring males have greater opportunities to guard their paternity, and find that this mechanism can also select for male-biased care. Hence, we derive the conditions under which male care may be selected despite partial paternity and completematernity.

Pretransplant Intensive Care Unit Management and Selection of Grade 3 Acute-on-Chronic Liver Failure Transplant Candidates.

The aim of this study is to report on the liver transplantation (LT) activity and posttransplant outcome, over time, of patients with grade 3 acute-on-chronic liver failure (ACLF-3) in a single transplant center performing a large number of LTs for patients with ACLF-3. It aims at showing how pre-LT intensive care unit (ICU) management impacts post-LT outcomes, in particular through monitoring the transplantation for ACLF-3 model (TAM) score. A total of 100 patients who had ACLF-3 at the time of LT between 2007 and 2019 were included retrospectively. The cohort was divided in 2 periods, with 50 patients in each period. There was an increase in the number of patients with ACLF-3 who received an LT during the course of the study period and significantly higher 1-year post-LT survival rates in the second period compared with the first period (86% versus 66%, respectively; P=0.02). Interestingly, patients during both periods had similar severity profiles and scores apart from a significantly lower number of patients with TAM scores >2 at the time of LT in the second period compared with the first period (1 [2%] versus 11 [22%], respectively; P≤0.01). In addition, patients whose clinical condition improved in the ICU (with a TAM score downstaged between admission and LT) had significantly higher post-LT survival rates than those whose TAM score stayed the same or increased: 88% versus 70%, respectively (P=0.04). This study shows a learning curve in LT for patients with ACLF-3, with optimized ICU management and patient selection leading to increased numbers of LTs for patients with ACLF-3 and improved post-LT outcomes. It also delineates how the TAM score can be used to identify the optimal transplantability window for patients with ACLF-3.