Complex Medical Conditions Research Articles

"The SUMMIT Team is All I Got": perspectives of medically and socially complex patients seen in intensive primary care.

Context: There is great interest in intensive primary care (IPC) interventions to address the needs of medically and socially complex patients, however it is unknown how these interventions impact patient experience. Objective: Describe the experience of patients on the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an IPC for patients with complex needs at a federally qualified health center serving patients with high rates of homelessness. Study Design: Qualitative study using semi-structured interviews with 25 patients enrolled in the SUMMIT intervention. We conducted a thematic analysis using a hybrid inductive/deductive approach. Results: Prior to SUMMIT, patients often felt it was difficult to engage with the healthcare system, in part due to their complex medical conditions, but also factors including prior trauma, poverty, substance use, and providers' stigma. We identified four themes related to how and why patients felt SUMMIT improved their care: 1) Investment: Patients perceived the team as truly invested in them and expressed how the team walked side by side in their care journeys to overcome stigma, low-self efficacy, and prior negative experiences with the healthcare system 2) Family: Patients reported feeling a strong sense of family with SUMMIT team members and believed that the team had genuine duty and obligation toward them, interacting with them in a non-judgmental, culturally competent manner. 3) Feeling valued: Patients expressed that the team's flexible design, continuity of team membership, care coordination and addressing unmet needs and social determinants led them to feel valued and hope. 4) Evolution of self-efficacy: Patients experienced improved self-efficacy, and were able to engage with health care proactively, instead of avoiding care. Conclusion: Medically and socially complex patients experience trauma and stigma that shape perceptions of care. Patients appreciated humanizing interactions with team members along with the additional support SUMMIT provided to overcome barriers to care. They spoke of the team as family members who valued them and they recognized how the program had helped them take a more active role in improving their own health. Our findings suggest that effectiveness of IPC interventions may lie, in part, on the use of team members who have the skills and commitment to deliver non-judgemental, culturally competent, longitudinal relationship-focused care.

727 Novel silver based “suitâ€#157; dressing technique for Steven Johnson Syndrome and other cutaneous exfoliative conditions

IntroductionExfoliative skin conditions such as Steven Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN) and other significant drug related reactions are complex medical conditions that provide a challenge to the burn surgeon, especially with regards to local wound care. Various modalities of wound care require frequent dressing changes; however, these changes put the patient through significant pain and potentially harmful experiences that could lead to worse skin exfoliation, scarring and pigmentation changes. As part of our burn unit, we have created a dressing utilizing silver impregnated nylon sheets that limits the amount of wound care performed and therefore the amount of potential exfoliative damage.MethodsWe have employed this means of dressing in all our Steven Johnson patients with significant open or blistered areas. We performed a retrospective analysis looking at our patients who were admitted with Steven Johnson Syndrome/toxic epidermal necrolysis or other exfoliative skin disorder over the last 7 years. We had 52 patients who ranged from having 2-100% of skin involved with significant blistering or exposed areas. The suit is made specific to the patient as each area is measured and the silver sheets are formed to the patient and secured in place. The silver sheets are saturated with sterile water and rewet with saline every four hours and changed every three days.ResultsBy utilizing these silver-based dressings, we have limited the amount of dressing changes and concomitant pain for patients while also limiting skin infections to only 1 out of our 52 patients. For blisters on the face, a local antibiotic ointment was used; and once the skin lesions had healed, a moisturizing lotion was used.ConclusionsSteven Johnson Syndrome and other exfoliative skin conditions require significant wound care. By minimizing dressing changes, one can lessen the pain to patients and by utilizing dressings that are infused with silver, one can also potentially decrease the risk for infection as was seen in our patient population.

Device-related pressure ulcers: SECURE prevention. Second edition.

Device-related pressure ulcers: SECURE prevention. Second edition.

Predictors of clinician use of Australia’s national health information exchange in the emergency Department: An analysis of log data

ObjectiveThis study explores patient and context related factors associated with use of Australia’s national personally controlled Health Information Exchange (HIE), My Health Record, by emergency department (ED) clinicians. Materials and methodsA retrospective analysis explored secondary routinely-collected data including all patients who presented (between August 2019–2021) to the ED at a not-for-profit hospital in Melbourne. Presentation data were linked to the HIE access log-data, and human resources data. The primary outcome indicated HIE access by an ED pharmacist, doctor or nurse, within 3 days of the patient presenting to the ED, or not. Nine variables were explored with logistic regression, representing patient (gender, age, diagnosis) and other factors (presentation time, arrival method, referral, acuity/triage, length of stay, admitted into hospital). ResultsHIE is accessed in 17.43% of patient presentations to the ED, led by pharmacists (15.60%). Overall, as demonstrated in themultivariable analysis, increased HIE access was associated with increasing age, with the biggest effect for 75–84-year old’s (odd’s ratio 26.15; 95% confidence interval 15.37–44.50), when compared to < 4 years of age. HIE access was also significantly and positively associated with patients who were later admitted into hospital from theED (4.96; 4.61–5.34). ConclusionThe results suggest users of HIE in the ED employ the system to meet their needs, but not for all patients. To maximise value derived from HIE use, clinicians should target system access for patients where the benefit of accessing the record outweighs the cost - this research suggests that is for patients who are older in age and are likely to be admitted, potentially linked to greater condition complexity. If the use of a HIE is to improve the provision of care in the ED, the key stakeholders governing patient information within the HIE need to focus on improving clinician recording behaviours for older people and those suffering from complex medical conditions. Doctors and nurses lag behind with respect to the use of the HIE by pharmacists. Therefore, a focus on encouraging HIE engagement across these clinician groups is drastically required.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) – UNDERSTANDING THE FRAMEWORK &amp; ITS APPLICATION

A multidisciplinary care team is required to meet the various challenges faced to treat complex medical conditions like people facing chronic diseases. A tool that can function across professional boundaries and that can handle differences in perspective for various medical professionals is much needed. The International Classication of Functioning, Disability and Health (ICF),is used as common language to dene medical conditions.This paper discusses the ICF model, and tries to understand the classication and few of its applications in medical, social and educational sector.

Functional MRI research involving healthy children: Ethics, safety and recommended procedures.

This specific review aims to expose clinicians, researchers and administrators in hospitals to the importance, procedures and safety of fMRI studies to promote the increased utilisation of such studies in different geographical places worldwide. The child's brain is developing rapidly, both structurally and functionally. These functional changes can only be detected using functional scans generated from an MRI machine and referred to as a functional MRI (fMRI). This method may be used clinically in complex medical and surgical conditions (e.g., epilepsy surgery), but these days are often used for research purposes. However, due to ethical and logistical considerations, fMRI in the paediatric population is not widely and equally used in different geographical places. The benefits of using this method to define the functional changes occurring in the developing brain are discussed in this review, along with desensitisation methods recommended when working with this vulnerable population in research and even in a clinical setting.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia

Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach. Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

46XX testicular DSD SRY-Negative in a child with hypoplastic left heart syndrome

Disorders of Sex Development (DSD) refers to biological differences between phenotypic sex, gonad morphology and chromosomal material. A full-term infant was born with Hypoplastic Left Heart Syndrome (HLHS) and ambiguous genitalia. Karyotype revealed 46XX with no evidence of Y chromosome or SRY. Biopsy of both gonads revealed testicular tissue. Parents decided to rear the child as male. The child underwent extensive cardiac repair and is currently awaiting decision regarding urological repair. This case emphasizes the need for multidisciplinary care in the management of children with DSD associated with other complex medical conditions to ensure a timely diagnosis and multi-system, patient-centered treatment approach.

An Unusual Case of Deep Vein Thrombosis and Mycotic Aneurysms Secondary to &amp;lt;i&amp;gt;Salmonella&amp;lt;/i&amp;gt; Bacteraemia

Salmonella, a food-borne pathogen, can cause mild self-limiting gastroenteritis. However, immunocompromised hosts and older adults with complex medical conditions may develop a complicated form of bacteraemia, with a high mortality rate involving extra-intestinal foci of infection and mycotic aneurysms. We report the case of a 61-year-old man with poorly controlled diabetes mellitus, hypertension, dyslipidaemia, and congestive heart failure, who presented with unilateral left lower limb swelling, extensive deep vein thrombosis, and concomitant Salmonella bacteraemia. An oral anticoagulant and intravenous antibiotic therapy were initiated. Although the patient remained haemodynamically stable, he complained of constant left lower limb weakness and lower back pain. A computed tomography angiography scan of the thorax and abdomen revealed saccular aneurysms with contained hematoma of the left common iliac artery. The oral anticoagulant was discontinued, and an inferior vena cava filter was inserted as part of the venous thrombosis management. The patient was offered aorto-uni-iliac endovascular aneurysm repair and received intravenous antibiotic therapy, postoperatively, for six weeks. The postoperative blood cultures remained negative, and he was discharged with a course of ciprofloxacin administered orally. However, three months after the surgery, the patient died of recurrent septicaemia. This case illustrates the importance of remaining vigilant for potential endovascular complications of Salmonella bacteraemia, such as mycotic aneurysms and deep vein thrombosis, among high-risk patients. Further, this case highlights the challenges of eliminating Salmonella bacteraemia and its related complications, albeit treating it with both a prolonged course of medical therapy and surgical intervention.

Nutritional status of Human Immune virus-infected under-five children in North West Ethiopia

BackgroundGlobally, malnutrition affects nearly one-third of the 8 million deaths of under 5 years children. Malnutrition associated with the Human Immune virus (HIV) infection is a complex medical condition. The co-occurrence of malnutrition and HIV increase the rate of morbidity and mortality of children significantly. ObjectiveThis study aimed to assess nutritional status and associated factors of HIV-infected under-five children before antiretroviral therapy initiation in North West Ethiopia. MethodsAn institution-based cross-sectional study was conducted among 270 records of HIV-infected children who were visiting Debre Markos referral hospital and Felege Hiwot referral hospital from 2015 to 2017 in North West Ethiopia. Malnutrition was assessed among the participants using the World Health Organization Z-score charts. Data were entered using Epi-Data version 3.1 and analysis was done using STATA 14 statistical software. The multivariable logistic regression model was fitted for each explanatory variable. Odds ratio with its 95% confidence interval with p-values < 0.05 were used to measure statistically significant association. ResultThe overall burden of malnutrition among HIV-infected under-five children was 27%; 10.7%, 17.8 %, and 15.9 % of wasting, stunting, and underweight respectively. Of all participants, 40% of them had a CD4 count below the threshold, 37.8% were in advanced stages of the disease and 17.8% of children had developed anemia. Seventeen percent of HIV-infected under-five children had opportunistic infections of which tuberculosis, pneumonia, and Kaposi’s sarcoma were highly observed. Age of children was significantly associated with malnutrition; older children were less likely to develop malnutrition as compared to infants (AOR: 0.15, 95% CI (0.07, 0.32)). ConclusionThe magnitude of malnutrition among HIV-infected children remains high in the study area. Therefore, measures should be strengthened in promoting nutritional education for HIV-positive children.

"SHARE. CARE. CURE." – A EUROPEAN REFERENCE NETWORK FOR RARE INFECTIOUS DISEASES

"SHARE. CARE. CURE." – A EUROPEAN REFERENCE NETWORK FOR RARE INFECTIOUS DISEASES

Bioinformatics analysis of candidate genes and potential therapeutic drugs targeting adipose tissue in obesity

ABSTRACT Obesity is a complex medical condition that affects multiple organs in the body. However, the underlying mechanisms of obesity, as well as its treatment, are largely unexplored. The focus of this research was to use bioinformatics to discover possible treatment targets for obesity. To begin, the GSE133099 database was used to identify 364 differentially expressed genes (DEGs). Then, DEGs were subjected to tissue-specific analyses and enrichment analyses, followed by the creation of a protein-protein interaction (PPI) network and generation of a drug-gene interaction database to screen key genes and potential future drugs targeting obesity. Findings have illustrated that the tissue-specific expression of neurologic markers varied significantly (34.7%, 52/150). Among these genes, Lep, ApoE, Fyn, and FN1 were the key genes observed in the adipocyte samples from obese patients relative to the controls. Furthermore, nine potential therapeutic drugs (dasatinib, ocriplasmin, risperidone, gemfibrozil, ritonavir, fluvastatin, pravastatin, warfarin, atorvastatin) that target the key genes were also screened and selected. To conclude the key genes discovered (Lep, ApoE, Fyn, and FN1), as well as 9 candidate drugs, could be used as therapeutic targets in treating obesity.

Use of Dietary Supplements and Perceived Knowledge among Adults Living with Fibromyalgia in Norway: A Cross-Sectional Study.

Fibromyalgia syndrome (FMS) is a complex medical condition characterized by widespread musculoskeletal pain. To date, no gold standard treatment has been developed, and persons with FMS often seek alternative methods to control their symptoms, such as dietary supplements (DS). This study aimed to describe the use of DS in persons living with FMS and examine the associations between the use of DS and its potential predictors. We recruited a convenience sample of 504 participants (≥18 years) living with FMS. The main outcome variables included estimated expenditure on DS in the last 12 months in Norwegian kroner (NOK) and the differences between the groups of users and non-users of DS. Of the 504 participants, 430 reported having used DS, and the mean amount of money spent in the previous year was determined to be NOK 2300. The most common DS reported were vitamin D, magnesium, and omega-3 fatty acids. The predictors of being a DS user were high education, high self-reported knowledge of DS but low overall knowledge of health claims. Users of DS marketed for muscles/joints appear to spend more money on DS. The increasing availability of DS and aggressive advertising in the media through health claims stipulate the need for interventions that lead to informed decisions about DS.

A Transitional Care Model for Veterans With Complex Needs During COVID: The Behavioral Recovery Outreach (BRO) Team

The Veterans Health Administration’s Care for Patients with Complex Problems (CP)2 Program developed a national infrastructure to disseminate promising practice models to improve care for Veterans with complex medical, mental health, and/or neurocognitive conditions, who may also have behaviors disruptive to care. A strategic priority is improving safe and effective transitions to community care for Veterans with complex care needs, many of whom have historically been limited to VA settings as a result of behavioral concerns. The Behavioral Recovery Outreach (BRO) Team was the first model identified for national dissemination and evaluation at partner sites. Developed at VA Central Iowa, BRO is an interdisciplinary team model that identifies Veterans in long-term VA care settings with complex care needs to engage in individualized behavioral programing to manage/stabilize behaviors and safely transition them to more appropriate and less costly community settings. This symposium will describe the BRO team model, highlight the facilitators and barriers to nationally disseminating the BRO model with VA partner facilities, discuss adaptations in continuing community transitions following the COVID-19 pandemic, and describe program outcomes. The first speaker will discuss development of the BRO model and outcomes of a regional dissemination. The second speaker will present results from the program evaluation of the national dissemination. The final speaker will describe BRO Team expansion and lessons learned from the perspective of a VA partner facility. The (CP)2 Program Director will integrate findings and highlight implications for scaling and evaluating promising models for national dissemination for policy, practice, and future research.

Brainstem Abnormalities in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Scoping Review and Evaluation of Magnetic Resonance Imaging Findings.

Background: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a multisystem medical condition with heterogeneous symptom expression. Currently, there is no effective cure or treatment for the standard care of patients. A variety of ME/CFS symptoms can be linked to the vital life functions of the brainstem, the lower extension of the brain best known as the hub relaying information back and forth between the cerebral cortex and various parts of the body.Objective/Methods: Over the past decade, Magnetic Resonance Imaging (MRI) studies have emerged to understand ME/CFS with interesting findings, but there has lacked a synthesized evaluation of what has been found thus far regarding the involvement of the brainstem. We conducted this study to review and evaluate the recent MRI findings via a literature search of the MEDLINE database, from which 11 studies met the eligibility criteria.Findings: Data showed that MRI studies frequently reported structural changes in the white and gray matter. Abnormalities of the functional connectivity within the brainstem and with other brain regions have also been found. The studies have suggested possible mechanisms including astrocyte dysfunction, cerebral perfusion impairment, impaired nerve conduction, and neuroinflammation involving the brainstem, which may at least partially explain a substantial portion of the ME/CFS symptoms and their heterogeneous presentations in individual patients.Conclusions: This review draws research attention to the role of the brainstem in ME/CFS, helping enlighten future work to uncover the pathologies and mechanisms of this complex medical condition, for improved management and patient care.

“Prix Fixe” or “À La Carte”? Pediatric Decision Making When the Goals of Care Lie in the Zone of Parental Discretion

For many children with complex medical conditions, decisions regarding their goals of care lie in the zone of parental discretion. That is, clinicians appropriately recognize that in many cases whether to prioritize quantity of life or quality of life is a deeply personal, values-laden decision best made by those who are most deeply invested in the outcome. Once a family has committed to a goal, however, there may be new or ongoing conflict between parents and clinicians regarding the specific interventions provided or not provided in support of that goal. To what extent is it ethically permissible for a seriously ill child's surrogate decision makers to reject individual interventions that support their desired goal of care? This question might be best described thus: is pediatric healthcare "prix fixe," in which clinicians help parents decide the best of one or more set combinations ("menus") of interventions, or is it "à la carte," in which parents are free to accept or reject each individual intervention? We argue that the concept of a "prix fixe" approach should be discussed with families early in the development of the clinical relationship, as an essential facet of shared decision making.

Medication-induced Pulmonary Injury: A Scenario- and Pattern-based Approach to a Perplexing Problem.

Medication-induced pulmonary injury (MIPI) is a complex medical condition that has become increasingly common yet remains stubbornly difficult to diagnose. Diagnosis can be aided by combining knowledge of the most common imaging patterns caused by MIPI with awareness of which medications a patient may be exposed to in specific clinical settings. The authors describe six imaging patterns commonly associated with MIPI: sarcoidosis-like, diffuse ground-glass opacities, organizing pneumonia, centrilobular ground-glass nodules, linear-septal, and fibrotic. Subsequently, the occurrence of these patterns is discussed in the context of five different clinical scenarios and the medications and medication classes typically used in those scenarios. These scenarios and medication classes include the rheumatology or gastrointestinal clinic (disease-modifying antirheumatic agents), cardiology clinic (antiarrhythmics), hematology clinic (cytotoxic agents, tyrosine kinase inhibitors, retinoids), oncology clinic (immune modulators, tyrosine kinase inhibitors, monoclonal antibodies), and inpatient service (antibiotics, blood products). Additionally, the article draws comparisons between the appearance of MIPI and the alternative causes of lung disease typically seen in those clinical scenarios (eg, connective tissue disease-related interstitial lung disease in the rheumatology clinic and hydrostatic pulmonary edema in the cardiology clinic). Familiarity with the most common imaging patterns associated with frequently administered medications can help insert MIPI into the differential diagnosis of acquired lung disease in these scenarios. However, confident diagnosis is often thwarted by absence of specific diagnostic tests for MIPI. Instead, a working diagnosis typically relies on multidisciplinary consensus. ©RSNA, 2021.

Rhabdomyolysis due to unaccustomed exercise: Experiences from a multidisciplinary clinic

Purpose: The Highly Specialised Service (HSS) for McArdle disease and related disorders in the United Kingdom receives many referrals to investigate the cause of exercise-induced pain and rhabdomyolysis, a complex medical condition involving rapid breakdown of damaged skeletal muscle. An increasing number of these referrals are following unaccustomed exercise. Since January 2017 twenty two such patients have been assessed in clinic. A typical history reveals either a period of inactivity followed by an intense training session at the gym, often with a personal trainer, prior to an episode of rhabdomyolysis. The aim of this service evaluation is to highlight the need for caution in training individuals returning to exercise, particularly after a break from exercise of at least two months.

Dynamics of biomarkers across the stages of traumatic spinal cord injury - implications for neural plasticity and repair.

Traumatic spinal cord injury (SCI) is a complex medical condition causing significant physical disability and psychological distress. While the adult spinal cord is characterized by poor regenerative potential, some recovery of neurological function is still possible through activation of neural plasticity mechanisms. We still have limited knowledge about the activation of these mechanisms in the different stages after human SCI. In this review, we discuss the potential role of biomarkers of SCI as indicators of the plasticity mechanisms at work during the different phases of SCI. An extensive review of literature related to SCI pathophysiology, neural plasticity and humoral biomarkers was conducted by consulting the PubMed database. Research and review articles from SCI animal models and SCI clinical trials published in English until January 2021 were reviewed. The selection of candidates for humoral biomarkers of plasticity after SCI was based on the following criteria: 1) strong evidence supporting involvement in neural plasticity (mandatory); 2) evidence supporting altered expression after SCI (optional). Based on selected findings, we identified two main groups of potential humoral biomarkers of neural plasticity after SCI: 1) neurotrophic factors including: Brain derived neurotrophic factor (BDNF), Nerve growth factor (NGF), Neurotrofin-3 (NT-3), and Insulin-like growth factor 1 (IGF-1); 2) other factors including: Tumor necrosis factor-alpha (TNF-α), Matrix Metalloproteinases (MMPs), and MicroRNAs (miRNAs). Plasticity changes associated with these biomarkers often can be both adaptive (promoting functional improvement) and maladaptive. This dual role seems to be influenced by their concentrations and time-window during SCI. Further studies of dynamics of biomarkers across the stages of SCI are necessary to elucidate the way in which they reflect the remodeling of neural pathways. A better knowledge about the mechanisms underlying plasticity could guide the selection of more appropriate therapeutic strategies to enhance positive spinal network reorganization.

Measuring the effects of nurse practitioner (NP)-led care on depression and anxiety levels in people with multiple sclerosis: a study protocol for a randomized controlled trial

BackgroundCanada has one of the highest rates of multiple sclerosis (MS) in the world. Treatments and supports for people with MS (PwMS) have become increasingly complex, requiring individualized and adaptive care. Specialized NPs provide advanced skills to those with complex medical conditions, with potential to enhance the health, functioning, and quality of life for PwMS. This study aims to determine the effect of a Nurse Practitioner (NP) on depression and anxiety levels in PwMS.MethodsWe will perform a parallel randomized controlled trial. PwMS who are followed by general private-practice neurologists will be randomly assigned to the intervention group (NP-led care) or the ‘usual care’ control group (general neurologist or family physician and registered nurse support). In the intervention group, the NP will assess and provide care to the MS patient and their caregiver at a baseline visit, with 3-month and 6-month follow-up visits. PwMS in the control group will receive usual care provided by their community neurologists or family physicians with the standard assistance provided by registered nurses experienced in MS care. The primary outcome will be the difference in change in the patient’s anxiety and depression scores as measured by the validated Hospital Anxiety and Depression Scale (HADS) questionnaire at 3 months. Secondary outcomes will include difference in change in HADS at 6 months; Modified Fatigue Impact Scale scores (MSIF) at 3 and 6 months; EQ-5D scores at 3 and 6 months; caregiver health-related quality of life in MS measures (CAREQOL-MS) at 3 and 6 months; number of visits and phone calls to healthcare professionals recorded by patient, and satisfaction with NP-led care vs usual care measured by the validated Consultant Satisfaction Questionnaire.DiscussionFindings from this study will contribute to exploring benefits of advanced nursing practitioner interventions for PwMS followed by general neurologists and family physicians in a community setting. It will provide evidence of the benefits of NP-led care for PwMS and offer an alternative healthcare resource for management of MS.Trial registrationClinicalTrials.govPro00069595. Retrospectively registered on June 26, 2020. Protocol version: January 2017, version 1.