Complex Medical Histories Research Articles

How Craniofacial Anomalies Can Obscure the Diagnosis of Unilateral Auditory Neuropathy Spectrum Disorder: A Case Study.

Comorbidities are common with craniofacial anomalies and can include auditory neuropathy spectrum disorder (ANSD). Identification of these comorbidities, such as a diagnosis of ANSD, has increased with expanded multi-disciplinary care teams and the use of auditory objective measures. Patients with craniofacial anomalies often have complex medical histories including extreme prematurity and jaundice, which may lead to the development of additional comorbidities. The 5-year-old boy that is the subject of this case study presented with noted developmental delays and residing in foster care with an unknown family/medical history. Initially presenting with middle ear dysfunction, exacerbated by craniofacial anomalies, the underlying cause of his speech delays was missed. Behavioral audiometry was attempted with inaccurate results. Surgery was performed to correct the craniofacial anomalies, middle ear dysfunction, and was followed with auditory brainstem response (ABR) testing. The boy healed well without complications. The ABR revealed ANSD, hearing aids were fitted for the diagnosis, regular speech therapy was initiated, and the boy continues to make steady progress toward developmental milestones. The purpose of this case study was to highlight the course of identification and treatment of a complex case that may provide insight into determining a differential diagnosis of ANSD when initially obscured by craniofacial anomalies.

Mental sequelae of the COVID-19 pandemic in children with and without complex medical histories and their parents: well-being prior to the outbreak and at four time-points throughout 2020 and 2021

The objective of this study is to understand the long-term mental sequelae for families over the course of the COVID-19 pandemic by longitudinally investigating the well-being of children with and without complex medical histories and their parents. Well-being of 200 children (between 7 and 18 years of age; 73 typically developing, 46 born very preterm, 73 with complex congenital heart disease) and 175 of their parents was assessed prior to and during the first (April–May 2020), second (October–November 2020), third (April–May 2021), and fourth wave (October–November 2021) of the pandemic with standardized questionnaires. Linear mixed models were used to investigate longitudinal changes in child and parent well-being compared to before the pandemic. Social and COVID-19-specific determinants were investigated as predictors of impaired well-being. To illustrate clinical relevance, the proportion of children and parents scoring > 1 SD below normative mean/median was reported. Compared to before the pandemic, child proxy-reported well-being was lower during the first but not the second, third, and fourth waves. Child self-reported well-being was not lower during the pandemic compared to before. Parent well-being dropped during the first wave and remained low throughout the subsequent waves. Proxy-reported child and self-reported parent well-being was lower in families with sparse social support and poor family functioning. Parents of typically developing children reported lower well-being than parents of children born very preterm or with a complex congenital heart disease. In November 2021, 20% of children (both self- and proxy-report) and 24% of parents scored below the normal range compared to 11% (child self-report), 10% (child proxy-report), and 16% (parent self-report), respectively, before the pandemic. The pandemic continues to impact the well-being of parents of school-aged children with and without complex medical histories more than 1 year after its outbreak. Children’s well-being was specifically affected during the first wave of the pandemic and has recovered thereafter. Families with sparse social support and poor family functioning are particularly at risk for compromised well-being and support should be provided to them.

Overview of use, efficacy, and safety of dupilumab in complex patients: a retrospective, case-series study from a large, urban academic center.

Dupilumab has emerged as an effective treatment option for those suffering from moderate-to-severe atopic dermatitis (AD). Since its approval in 2017 by the United States Food and Drug Administration, dupilumab demonstrated efficacy in a wide range of "off-label" dermatologic conditions. With its increasing use, dermatologists must navigate prescribing dupilumab in complex patient populations. To that end, we performed a single-institution, retrospective, case-series study to assess efficacy, tolerability, and safety of dupilumab in elderly, patients on concomitant immunosuppressive/immunomodulating therapies, and those with pre-existing co-morbidities (e.g., malignancies, chronic renal and/or liver diseases, organ transplantation, hematologic malignancies, and infection). We conducted chart reviews of 248 patients who were prescribed dupilumab between January 1, 2017 and August 31, 2021, and identified 64 patients who met the criteria of being in the complex patient group as described above. Our results showed that 87.5% (56/64) of complex patients demonstrated improvement and/or disease clearance on dupilumab. 20.3% (13/64) of them experienced one or more side effects reported as conjunctivitis, seborrheic dermatitis, psoriasiform eruption, xerosis, facial burning sensation, anaphylactic reaction/angioedema, and worsening of AD. 9.4% (6/64) of them discontinued dupilumab due to the side effects. These findings demonstrated that dupilumab can be safely considered in certain complex patient populations such as elderly and those with significant pre-existing co-morbidities and can be safely combined with immunosuppressive medications and/or other biologic therapies. In the future, more studies with long-term follow-up are needed to validate the efficacy and safety of dupilumab in these challenging patients with complex medical histories.

Wastewater surveillance for rapid identification of infectious diseases in prisons

Wastewater surveillance for rapid identification of infectious diseases in prisons

Genetic diagnosis of immune dysregulation can lead to targeted therapy for interstitial lung disease: A case series and single center approach.

In recent years, a growing number of monogenic disorders have been described that are characterized by immune dysregulation. A subset of these "primary immune regulatory disorders" can cause severe interstitial lung disease, often recognized in late childhood or adolescence. Patients presenting to pulmonary clinic may have long and complex medical histories, but lack a unifying genetic diagnosis. It is crucial for pulmonologists to recognize features suggestive of multisystem immune dysregulation and to initiate genetic workup, since targeted therapies based on underlying genetics may halt or even reverse pulmonary disease progression. Through such an approach, our center has been able to diagnose and treat a cohort of patients with interstitial lung disease from gene defects that affect immune regulation. Here we present representative cases related to pathogenic variants in three distinct pathways and summarize disease manifestations and treatment approaches. We conclude with a discussion of our perspective on the outstanding challenges for diagnosing and managing these complex life-threatening and chronic disorders.

Paper Patients: When Documents Stand in for Patients

This article analyses a seemingly mundane feature of a mental health centre for immigrants and refugees in Paris: the documents used by budding therapists undertaking their apprenticeships. Supervisors developed these documents in order to train therapist apprentices to learn the explanatory models of patients, identify the voice of patients, and incorporate medical anthropology into their therapeutic practice. The documents were central to the experiences of therapist apprentices because they occupied most of their time and were a substitute for supervision and patient contact. Documents disciplined the speech of therapist apprentices and focused their attention on specific aspects of patients’ histories. Therapist apprentices found these documents and documentary practices to be problematic because they reduced patients’ complex migration and medical histories to a series of tick boxes and short answers. These documents generated new forms of uncertainty among therapist apprentices about how to present clinical information about patients to their supervisors. This article is part of a larger study that considers mental health services for immigrants and refugees as communities of practice in which therapist apprentices learned to develop clinical and caring skills for vulnerable patient populations. By drawing on and contributing to scholarship on apprenticeship, uncertainty, documents, and bureaucracy, this article demonstrates how bureaucratic processes and documentary artefacts may generate unnecessary forms of uncertainty and hinder participation in communities of practice.

Developing telemedicine in Emergency Medical Services: A low-cost solution and practical approach connecting interfaces in emergency medicine

Background:In Germany, the number of calls for Emergency Medical Services (EMS) are increasing, while the number of general practitioners and hospitals are decreasing, resulting in a growing demand and workload for emergency physicians and paramedics. Furthermore, an aging population with increasingly complex medical histories, present emergencies in which a more detailed assessment and therapies are urgently needed. Therefore, common EMS systems need to find solutions to handle these problems.Methods:We used a user-focused five-step approach to define a technological solution: Research of current systems, definition of goals and requirements, development of concept, test series and evaluation, evaluation of costs and benefits.Results:Development of a holistic telemedical concept to connect in-hospital clinical emergency physicians and paramedics on the scene, by implementing and connecting systems that are already partially being used in common EMS in Germany. By using live audio and video communication, including vital signs between the two, a system can be established by keeping costs low, affordable and at the same time protecting patient data in line with General Data Protection Regulation.Conclusion:Implementing technologies in a practical specialty like Emergency Medicine with a user-focused approach demonstrates that the hurdle for integration into established routines can improve current processes. Evaluation of costs and usability is a main driver to define success of such concepts and can improve if such systems can be developed to be used in larger networks.

Virtual Ileostomy as an Option for Complicated Colorectal Resections.

When surgery requires a colorectal anastomosis, a diverting ostomy may be created to decrease the clinical impact of anastomotic failure. Unfortunately, diverting ileostomies are also associated with significant morbidity. Recent literature suggests that diverting ostomies are not necessary for the majority of patients undergoing colorectal anastomosis and that creation of a virtual ileostomy (VI) may spare patients the complications that accompany diverting ileostomy creation. We present 4 patients with complex medical histories who underwent colorectal resections with primary anastomoses and VI creation. None of these patients suffered anastomotic leak or required conversion of VI to defunctioning ileostomy and there were no major complications associated with VI creation. Our results, although limited by sample size, support the creation of a virtual ileostomy as a safe and effective alternative to diverting ileostomy creation at the time of colorectal anastomosis.

Students' Perceptions Regarding the Influence of a Home Health Interprofessional Simulation Experience: A Mixed-Methods Study

Introduction: Interprofessional health care teams are essential for clinical decision making when providing care for patients with complex medical histories in the community setting. The purpose of this mixed methods, quasi-experimental study was to explore health care students' perceptions of communication and collaboration after an interprofessional simulation in a community health environment. Although interprofessional collaboration in community settings has been shown to improve patient outcomes and perceived quality of life, little emphasis has been placed on how to prepare future health care providers for interprofessional practice in this challenging environment. Methods: This study used a sample of convenience of 87 health care students (30 physical therapist students, 34 nursing students, and 23 emergency medical services students) enrolled in 2 education institutions in Southwest Virginia. Quantitative data were collected using the 21-item Interprofessional Socialization and Valuing Scale (ISVS-21). Qualitative data, collected through focus group interviews, were analyzed using thematic analysis. Results: Overall, students improved their perception on all items on the ISVS-21. The students in this study were also able to reflect on their profession's role in the community health setting, discuss key information to be shared to ensure the continuity of patient care, and explore an effective handoff process between professions. Discussion and Conclusion: Students gained understanding of each professions' perceptions of care priorities in the community and the different communication strategies may better prepare the students to enter the diverse and complex community health care environment.

The relationship between quality of housing and quality of life: evidence from permanent supportive housing

ABSTRACT State Medicaid expansion, coupled with financial incentives from alternative payment models, have fostered an increase in housing programs supported and implemented by hospitals and health systems. Permanent supportive housing (PSH) can improve patients’ health, quality of life (QOL) and wellbeing, and reduce healthcare costs over the long-run. Yet, there is limited research to understand the challenges and opportunities that arise, particularly with regards to housing quality, when stakeholders such as health plans decide to operate PSH programs. We describe a PSH program administered by a large Medicaid managed care plan, serving individuals experiencing homelessness with complex medical histories, and outline participants’ perceptions (n = 22) on the relationship between quality of housing and QOL – including physical health, mental health and social wellbeing. Findings indicate perceived improvements in physical, mental, and social aspects of QOL were attributed to housing stability, location, and quality. However, participants also highlighted stressors perceived to diminish QOL, particularly issues with the location and physical characteristics of the housing environment, challenging relationships with landlords and perceived discrimination. These results offer policy implications, including identifying roles for local and regional stakeholders to improve PSH programs by enhancing housing inspections, code enforcement, and prospectively tracking participant QOL.

Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity.

The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children. The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision. The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion. Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.

Pharmacological Management of Spontaneous Intracerebral Hemorrhage in Older Adults

Pharmacological management of intracerebral hemorrhage in adult patients over 65 years of age requires special considerations due to differing clinical presentations, underlying organ dysfunction, and more complex medical histories and medication profiles. A literature review of articles focusing on the age-specific pharmacological management of intracerebral hemorrhage was conducted. Treatment approaches and clinical outcomes specific to older adults were evaluated and therapeutic considerations for this population are summarized. Older adults were commonly included in trials regarding reversal of anticoagulants and antiplatelet agents and these results are generalizable to older adults. Underlying organ dysfunction should frequently be considered throughout the treatment of intracerebral hemorrhage in older adults. Older adults with intracerebral hemorrhage should be managed similarly to younger adult patients; however, consideration of age-related comorbidities and physiological differences is critically important for optimizing patient care.

Advances in Diagnosis of Mitochondrial Diseases: Case Report of an Infant with Pearson Syndrome

Pearson syndrome (PS) is a mitochondrial disorder that presents in early infancy as a multisystemic disease affecting the bone marrow and pancreas. It may present with anemia, diarrhea, exocrine pancreatic dysfunction, and failure to thrive.[1] Delay in diagnosis can lead to severe morbidity and mortality in infancy. We report the case of a 9-month-old presenting with failure to thrive, severe macrocytic anemia and pancytopenia initially thought to have gastroesophageal reflux and feeding intolerance. Severe macrocytic anemia and pancytopenia prompted an early bone marrow evaluation. Abnormal bone marrow findings including vacuolated marrow precursors and ringed sideroblasts along with persistent mild lactic acidosis led to a rapid and extensive genetics workup. Whole exome sequencing including mitochondrial genome sequencing detected a 2.3 kb heteroplasmic deletion in m.12113_14421 encompassing the MT-ND5 gene consistent with the diagnosis of Pearson Syndrome. This case report highlights the advances in molecular genetic testing to diagnose patients with complex medical histories along the spectrum of mitochondrial diseases and the importance of early diagnosis to start treatment.

Primary care referrals to nephrology in patients with advanced kidney disease.

Optimizing care for patients with advanced kidney disease requires close collaboration between primary care physicians (PCPs) and nephrologists. Factors associated with PCP referral to nephrology were assessed in patients with estimated glomerular filtration rates (eGFRs) less than 30 mL/min/1.73 m2. Electronic health record review at an integrated health care network. Factors associated with referral status were identified using Fisher's exact tests, t tests, and multivariable logistic regression. Of 133,913 patients regularly seeing PCPs between October 2017 and September 2019, 1119 had a final eGFR less than 30 mL/min/1.73 m2 and were not on renal replacement therapy. Care was provided by 185 PCPs (61 practices). Analyses were restricted to the 97.1% (n = 1087) of patients who were African American or European American. Of these, 54.6% had not been referred to nephrology. Nonreferred patients had higher numbers of PCP visits (P = .004). In contrast, referred patients were younger, were more often African American, and had PCPs at the academic medical center (all P < .0001). Referred patients had more complex medical histories with higher Charlson Comorbidity Index scores, more hospitalizations, and greater numbers of inpatient days (all P < .0001). Analyses restricted to patients with serum creatinine concentration of at least 2 mg/dL yielded similar results. Age, number of hospitalizations, ancestry, academic physician, diabetic end-organ damage, peripheral vascular disease, and tumor status were independent predictors of nephrology referral. Impediments to appropriately timed nephrology referrals persist in patients with high likelihoods of progression to end-stage kidney disease. Improved access to nephrology care should be rapidly addressed to meet targets in the 2019 Executive Order on Advancing American Kidney Health.

A case series illustrating the implementation of a novel tele-neuropsychology service model during COVID-19 for children with complex medical and neurodevelopmental conditions: A companion to Pritchard et al., 2020

Objective: Despite a movement toward tele-based clinical services in other healthcare domains, implementation of these services within neuropsychology, particularly with pediatric populations, is limited. With the onset of social distancing due to COVID-19, the field of pediatric neuropsychology is encouraged to consider the utility of non-traditional, tele-neuropsychological assessments. In order to accommodate ongoing service needs for medically and neurodevelopmentally complex children, a novel three-tiered telehealth service model of care was developed and implemented in a large pediatric outpatient neuro/psychological clinic within an academic medical center.Method: In this article, we provide case examples that illustrate the clinical implementation of this three-tiered telehealth service model of care for serving children during this uncertain time.Conclusion: The primary aim of this article is to provide examples outlining how clinical service decisions were made in the application of this three-tiered model for children with complex medical and neurodevelopmental histories. This article is intended to serve as a guide for other pediatric neuropsychology providers considering tele-neuropsychological services for complex pediatric patients during social distancing.

Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review

To assess characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence. We conducted a retrospective study of consecutive patients (birth to age 21years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding. Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39±1kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up. Our findings support the effectiveness of our intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. Further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

Predicting hospital admission for older emergency department patients: Insights from machine learning

BackgroundEmergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications. Materials and methodsWe analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation. ResultsGradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition. ConclusionTo the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

Safety and Efficacy of Colored Iris Reconstruction Lens Implantation

We sought to evaluate the 1- to 9-year safety and efficacy of colored iris reconstruction lens implantation in eyes with visual disturbances caused by partial or complete aniridia. Prospective, interventional case series. Thirty-eight patients were implanted with Ophtec 311 colored iris reconstruction lenses at the University of California, Los Angeles as part of a larger U.S. Food and Drug Administration clinical trial. Patients in group 1 lacked corneal pathology. Patients in group 2 patients had corneal pathology, such as endothelial failure, previous transplants, or scarring. Safety measures included loss of corrected distance visual acuity (CDVA), surgical complications, adverse events, secondary interventions, and corneal endothelial cell loss. Efficacy measures included improvement in uncorrected distance visual acuity (UDVA) and subjective visual disturbances. Groups 1 (n= 8) and 2 (n= 30) showed improvements in CDVA (P= .155 and .038), UDVA (P= .002 and P < .001), and subjective visual disturbance scores at year 3. Median CDVA and UDVA declined slightly for both groups after 1-2 years. Group 2 experienced more adverse events, surgical complications, and secondary interventions. Endothelial cell loss was greater for group 2 (19.7%) than group 1 (8.05%), although this difference was not statistically significant (P= .067). Colored iris reconstruction lens implantation improved CDVA, UDVA, and subjective visual disturbances 3 years postoperatively and beyond. Adverse events, complications, and subsequent declines in visual acuity were common, however, in these eyes with complex medical and surgical histories.

Application of Laser Technology in Fixed Prosthodontics &amp;lt;br/&amp;gt;—A Review of the Literature

Introducing laser light in prosthetic dentistry opens a new era on the treatment modules with new impact in the quality of prosthodontics treatments, with hope of overcoming some of the drawbacks posed by the conventional methods of fixed prosthodontics procedures. Laser techniques cause less pain than traditional methods and eliminate the noise of instrumentals that some fearful patients who have long term neglected care and those have complex medical histories and required more specialized care, could use the advantage of laser in their treatment plan. The aim of the articles review is to highlight the current and emerging application of laser in fixed prosthodontics treatment to be used in conjunction or as replacement for traditional methods based on the research that support the indication described.

Supporting the Transition to Practice for Nurse Residents on a Multispecialty Unit

Supporting the Transition to Practice for Nurse Residents on a Multispecialty Unit