Complex Medical Issues Research Articles

Advancing Specialist Geriatric Medicine Training: A Successful Introduction to Simulation-Based Training

Abstract Background Simulation-based education (SBE) has been adopted by various specialties and is used to complement other aspects of education. Geriatric medicine is a diverse specialty, requiring healthcare professionals (HCPs) to navigate complex social, medical, and ethical issues, necessitating a multifaceted and interdisciplinary approach making SBE the ideal vehicle to train geriatric medicine trainees. SBE is currently not a formal component of geriatric medicine training in Ireland and trainees experience varying levels of exposure to SBE. To address this, WICOPSIM in collaboration with the Royal College of Physicians (RCPI) facilitated a study day for geriatric medicine trainees demonstrating the design and implementation of gerontological SBE. Methods A faculty consisting of RCPI Irish Clinician Educator Track (ICET) training fellow, WICOP simulation fellow and two Consultant Geriatricians coordinated the event. All geriatric medicine trainees were invited to a one-day SBE event hosted by WICOPSIM. Lectures on simulation theory and application preceded a simulation scenario demonstration focusing on the interdisciplinary management of a patient whose capacity was in question; followed by a SBE participant workshop. Results Fifty-two trainees attended the event. Forty-five trainees completed the post-event survey. 98% (n=44) were satisfied with the variety of topics presented and felt more prepared to design and run a scenario. The simulation demonstration, debrief and design workshop met 100% trainees’ expectations. All trainees indicated that SBE should be a routine element of geriatric medicine training. 69% (n=31) intend to run SBE within their own department in the future. Conclusion This event successfully introduced geriatric medicine trainees to the design principles and practices of gerontological SBE. SBE offers trainees the opportunity to practice the technical and non-technical skills required to navigate complex, interdisciplinary and challenging scenarios, in a protected environment. The positive feedback generated suggests SBE is a useful tool to enhance the specialist geriatric medicine training experience and warrants further exploration.

Debulking the Myth of the ‘Social’ Admission – A Retrospective Review of Acutely Admitted Medical Patients in Wexford General Hospital

Abstract Background “Acopia”, “social admission” and other synonymous terms are frequently provided reasons requiring admission to acute hospitals and represent a common encounter for the Geriatric clinician. These cases are usually so called when the patient’s social circumstances are felt to need urgent attention, yet their medical health has not acutely deteriorated. Such non-diagnostic labels often mask underlying complex medical issues which can have detrimental health outcomes if not addressed appropriately. Despite this, they persist in the vernacular of modern medicine with almost half of doctors, junior and senior, finding the term useful (43.5%) and acceptable as a diagnosis (30.9%)1. We sought to examine what percentage of adult medical patients admitted to an acute hospital did not have an appreciable medical cause for their presentation. Methods We conducted a retrospective review of 191 patients admitted under medical teams in Wexford General Hospital across a 13-day period. Inclusion criteria included adult patients admitted under a medical team from the Emergency Department. Exclusion criteria applied to any patient admitted from OPD or by non-medical specialities. Results 191 cases were analysed. The average age was 65.8, median age was 70 and majority were male (n=105, 55%). There were only 2 patients (1%) who had no acute medical concerns following medical review. In one, the patient’s home oxygen supply had run out and the intended delivery of oxygen had been delayed. Another patient required increased home care supports however their medical status had not changed. Conclusion Our findings suggest that most patients presenting to acute hospitals following a robust medical review will evidence an acute medical issue. Dismissive phrases such as “acopia” and “social admission” need to be challenged for the superficial assessment that they are, and this reductive approach must be expunged from clinical practice to avoid misdiagnosis and malpractice in the care of the older adult.

Home care needs assessment among caregivers of children and adolescents with osteogenesis imperfecta: a cross-sectional study

BackgroundChildren and adolescents with complex medical issues need home care services; however, few studies have provided insight into the unmet home care needs of the families of patients with osteogenesis imperfecta (OI). In this study, we aimed to assess the home care needs of caregivers of children and adolescents with OI and the associated factors.MethodsA self-administered questionnaire was administered online to 142 caregivers of patients with OI aged 3–17 years between May and October 2022 from 25 provinces in China. The questionnaire comprised 15 questions on demographic variables and 14 questions on home care needs. Chi-square analysis was used to compare group differences for categorical variables. Multivariate binary logistic regression analysis was conducted to examine predictors of caregivers’ home care needs.ResultsThe study findings indicated that 81.5% of caregivers had high home care needs. The three leading types of home care needs were helping the child carry out physical fitness recovery exercises at home (72.5%), understanding precautions regarding treatment drugs (72.5%), and relieving the child’s pain (70.4%). OI patients’ poor self-care ability (adjusted odds ratio = 5.9, 95% confidence interval = 1.8–19.0) was related to caregivers’ high level of home care needs.ConclusionsThe findings of this study suggest that future scientific research and nursing guidance should focus on OI patients’ physical training, medication management, pain relief, fracture prevention, and treatment. In addition, caregivers of patients with poor self-care ability should receive special attention in the development of interventions. This study can help with addressing the unmet home care needs of caregivers of children and adolescents with OI. It is vital to develop a personalized intervention plan based on patients’ self-care ability.

Exploring the influencing factors of patient safety competency of clinical nurses: a cross-sectional study based on latent profile analysis

BackgroundClinical nurses play an important role in ensuring patient safety. Nurses’ work experience, organizational environment, psychological cognition, and behavior can all lead to patient safety issues. Improving nurses’ attention to patient safety issues and enhancing their competence in dealing with complex medical safety issues can help avoid preventable nursing adverse events. Therefore, it is necessary to actively identify the latent profiles of patient safety competency of clinical nurses and to explore the influencing factors.MethodsA cross-sectional design was conducted. A total of 782 Chinese registered nurses were included in the study. Demographic characteristics questionnaire, Error Management Climate scale, Security Questionnaire, Proactive Behavior Performance scale and Patient Safety Competency Self-Rating Scale of Nurses were used. Latent profile analysis (LPA) was performed to categorize nurses into latent subgroups with patient safety competency differences. Multinomial logistic regression was conducted to explore the influencing factors of nurses’ patient safety competency (PSC) in different latent profiles.ResultsA total of 782 questionnaires were valid. Nurses’ PSC was positively related to error management climate, and psychological safety and proactive behavior. The PSC score was 121.31 (SD = 19.51), showing that the PSC of clinical nurses was at the level of the medium on the high side. The error management climate score was 70.28 (SD = 11.93), which was at a relatively high level. The psychological safety score was 61.21 (SD = 13.44), indicating a moderate to low level. The proactive behavior score was 37.60 (SD = 7.33), which was at a high level. The latent profile analysis result showed that three groups of profile models were fitted acceding to the evaluation of PSC. They were defined as Low-competency Group (74 (9.5%)), Medium-competency Group (378 (48.3%)) and High-competency Group (330 (42.2%). Working years, professional titles, departments, error management climate, psychological security and proactive behavior were the influencing factors of PSC in three latent profiles.ConclusionsThe PSC of clinical nurses had obvious classification characteristics, and the main influencing factors were working years, professional titles, working departments, error management climate, psychological security and proactive behavior. This study suggests that managers should pay attention to the continuous cultivation of patient safety competence among clinical nurses, provide targeted intervention measures for nurses at different work stages, professional titles, and departments, and use efficient management strategies to create a positive error management atmosphere. In patient safety management, providing nurses with more psychological security is conducive to stimulating more proactive behaviors and continuously improving the level of patient safety competence.

Effect of Kangaroo Mother Care on Weight Gain in Low Birth Weight Preterm Infants

Background: Preterm birth, defined as delivery before the 37th week of pregnancy, often results in low birth weight and complex medical issues, necessitating additional care. Kangaroo Mother Care (KMC), which involves skin-to-skin contact with the mother or caregiver, is a recommended care approach for stable low birth weight infants. This study aimed to assess the impact of KMC on the weight gain of low birth weight preterm infants. Methods: This quasi-experimental study was conducted at the premature care unit of Al-Zahraa Teaching Hospital in Al-Najaf, Iraq, from May 2023 to April 2024. The study included 25 mother-infant dyads, where infants were preterm (<37 weeks gestation) and had a birth weight of <2000 grams. The intervention involved mothers practicing KMC for ≥6 hours/day. Data on gestational age, birth weight, gender, mode of delivery, feeding type, and weight gain were collected. Infant weight was measured at enrollment and discharge. Statistical analysis was performed using Jamovi software version 25, with significance set at P < 0.05. Results: The mean age of infants in the KMC group was 13.6±5.7 days, with 56% males and 44% females. Most infants (92%) had a birth weight of <1500 grams. There was a significant weight improvement at discharge (1178.8 ± 239.6 g) compared to admission (1094.8 ± 270.6 g), with an average weight gain of 85 grams (P < 0.001). Additionally, 72% of infants in the KMC group were exclusively breastfed. Conclusion: KMC significantly improves weight gain and breastfeeding rates in low birth weight preterm infants. The findings support the implementation of KMC as an effective care strategy in resource-limited settings to enhance infant health outcomes.

Юрій Дуброва (1955–2023) — біолог з України, якого чув світ: нотатки до біографії

The future famous geneticist Prof. Yuri Dubrova (1955–2023) was born in Kyiv (Ukraine), where he received excellent secondary and higher education and was awarded with a gold medal upon graduating from school. Eventually, he became one of the best graduates of the Department of Vertebrate Zoology at the Faculty of Biology of Taras Shevchenko National University of Kyiv. His interests included theoretical biology, evolutionary theory, genetics, biometrics, and bionics (for some time he studied the lateral lineage of cyprinid fishes). In his last years at the university, he focused on the study of spontaneous mutations. At the Vavilov Institute of General Genetics in Moscow, Y. Dubrova continued his post-graduate studies and successfully defended his PhD thesis. After the collapse of the USSR, he moved to the UK in search of better scientific and technical opportunities, where he became a professor at the University of Leicester. The scientist lived and worked in Leicester until the end of his life. He devoted himself fully to science, especially to radiation, medical and population genetics, and to teaching, and tried to participate in the study of highly complex medical and genetic issues related, in particular, to the consequences of man-made disasters—Chornobyl (Ukraine, Belarus), Semipalatinsk (Kazakhstan)—and other cases of large-scale radiation effects on life. Dr. Dubrova is the author and co-author of more than 150 scientific articles published in leading journals, including the American Journal of Human Genetics, International Journal of Radiation Biology, Radiation Research, Molecular Biology and Evolution, International Journal of Cancer, British Journal of Cancer, Science, and Nature. He co-operated with many of the world’s leading geneticists and gave lectures in Ukraine, Russia, the USA, Canada, Japan, etc. The article uses fragments of the author’s long correspondence with Y. Dubrova, which may be of interest to biographers of F. Dobrzhansky, M. Tymofeiev-Resovsky, O. Sozinov, O. Yablokov, O. Kistiakowsky, as well as to students, teachers, and historians of Kyiv National University, Kaniv Nature Reserve, and the University of Leicester.

Effects of hypermobile Ehlers-Danlos syndrome patients on the workflow and professional satisfaction of genetic counselors.

The Ehlers-Danlos syndromes (EDS), a group of uncommon connective tissue disorders, are, paradoxically, an increasingly common referral to genetics specialists. Of the 13 types of EDS, the most common is hypermobile EDS (hEDS), which lacks a known genetic etiology and for which diagnosis is achieved via a robust set of clinical criteria. While previous investigations have characterized many clinical aspects of EDS as a syndrome and patients' lived experiences, a gap in the literature exists regarding clinicians' experience caring for these individuals. This study sought to understand the effects of hEDS patient referrals from genetic counselors' perspectives. To capture these novel views and values, we conducted semi-structured interviews with 15 participants who were members of the National Society of Genetic Counselors (NSGC) and had experience working with the hEDS patient population. Interview questions explored the frequency of hEDS referrals in their clinic, investigated their roles and responsibilities as genetic counselors when working with this population, analyzed their workflow for this indication, assessed the impacts on their professional satisfaction, and explored potential options for improving workflow and care for the hEDS patient population. Reflexive thematic analysis yielded four themes: (1) Referrals for hEDS have generally increased over time and many institutions have implemented new policies to control this influx, (2) genetic counselors' primary roles include education and addressing psychosocial matters for this population, (3) genetic counselors feel both rewarded and challenged by these referrals, and (4) genetic counselors call for more education and training on hEDS for all healthcare specialties. Our findings provide a better understanding of the goals of the hEDS patient referrals to genetics specialists and the opportunities and challenges those referrals present. Genetic counselors have specific training and skills in psychosocial counseling and communication, in some ways making them ideal care providers for this population. However, they are simultaneously a scarce resource and the complex medical issues presented by many patients with hEDS make multidisciplinary management essential. We conclude with potential avenues for improving interactions with this population.

A Review of Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Therapy for Gastroesophageal Reflux Disease in Neonates and Infants.

Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are commonly used medications in neonates and infants for the treatment of gastroesophageal reflux disease (GERD), especially in neonatal intensive care units (NICUs). A literature review was conducted to evaluate the efficacy and safety of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) in preterm neonates, term neonates, and infants. A total of 27 studies were included in this review. Antacid medications in studies have consistently shown positive pharmacodynamic effects, including increasing gastric pH, reducing the reflux index, and reducing the number of acidic reflux events. The benefit found in placebo-controlled trials are limited exclusively to these surrogate outcomes. The actual clinically salient outcomes which H2RAs and PPIs are used for, such as reduction in GERD symptoms, especially irritability and improved feed tolerance and weight gain, have consistently shown no clinical benefit. H2RAs and PPIs appear to be extremely well tolerated by the neonatal and infant populations, which would mimic our experience with these medications in our unit. The available data from large, retrospective cohort and case-control studies paint a much more concerning picture regarding the potential for an increased risk in the development of allergies, anaphylactic reactions, necrotizing enterocolitis (NEC), other nosocomial infections, and lower respiratory tract infections. Given the risks associated with and lack of clinical effectiveness of both H2RAs and PPIs, use of these medications should be limited to specific clinical situations. Further studies are required to determine whether antacid pharmacologic therapy might benefit certain neonates and infants, such as those with complex medical issues.

Laparoscopically assisted percutaneous endoscopic gastrostomy performed for remnant stomach in patient with amyotrophic lateral sclerosis: a case report

BackgroundAlthough percutaneous endoscopic gastrostomy (PEG) offers better access to the gastrointestinal system, in patients with previous abdominal surgery, PEG can be unsuccessful. Laparoscopically assisted percutaneous endoscopic gastrostomy (LAPEG) is indicated for such patients. However, patients with amyotrophic lateral sclerosis (ALS) may be more susceptible to anesthesia-related complications than other patients, requiring the indications for LAPEG, along with perioperative management, to be considered carefully.Case presentationA 70-year-old, male patient with ALS was referred to our hospital for a gastrostomy for progressive dysphagia. He had undergone an open distal gastrectomy for gastric ulcer perforation in his twenties. Upper gastrointestinal endoscopy denied the transillumination sign and focal finger invagination. Because the risk of respiratory complications caused by general anesthesia was not considered serious, the decision was made to perform a LAPEG. Under careful, intraoperative airway management and neuromuscular monitoring, adhesiolysis was performed to increase mobility of the remnant stomach. A gastrostomy tube was inserted through the abdominal wall and into the remnant stomach under laparoscopic and endoscopic guidance. The patient was discharged in stable condition on postoperative day 3 without any respiratory complications.ConclusionsLAPEG was able to be performed in a patient with ALS with a previous gastrectomy. A perioperative team comprised of neurologists, endoscopists, surgeons, anesthesiologists, and nurses who are fully conversant with ALS must be assembled to deal with potentially complex medical issues related to the procedure and anesthetic and perioperative management.

The Multiple Punishment of Being an Older Adult Coping With Health Problems in Prison.

Studies have examined the vulnerabilities and the extent of health problems experienced by the older adult population in prison. However, reports about the subjective experiences of incarcerated older adults who are coping with health problems are scarce. This is alarming since older adults comprise the fastest-growing demographic in the prison systems of the United States and Europe. The aim of the current study was to bring forth the voices of older adults who are living with diseases in prison and to outline the landscape of struggling with everyday health care management. An interpretive phenomenological analysis was used to analyze the narratives of 23 individuals aged 60-88 who were coping with health problems in prison. The narratives revealed 3 major themes: (1) living day to day with illness in prison: fighting prison bureaucracy and public humiliation; (2) coping with complex medical issues: lack of professional medical care and cumulative problems, and (3) what does the future hold? Fear of living with illness out of prison. Intersectionality was used as a conceptual framework for understanding the participants' narratives. The cumulative effect of belonging to systematically oppressed and marginalized groups is discussed. The research findings point to issues and experiences that are unique to older adults coping with health problems in prison and can serve as a framework for developing tailored interventions for these individuals.

Healthy and Happy Citizens: The Opportunities and Challenges of Co-Producing Citizens’ Health and Well-Being in Vulnerable Neighborhoods

This explorative study aims to contribute to the debate about citizen involvement in (complex) medical and social issues. Our research goals are: (1) to explore the main opportunities, threats and challenges to co-producing healthcare in vulnerable communities from the perspective of professionals, co-producers (i.e., citizens with a volunteering role) and service users (i.e., patients); (2) to distil lessons for public managers concerning the main issues involved in designing co-production initiatives. We studied co-production initiatives in the Dutch city, The Hague. These initiatives were part of a broader, unique movement named ‘Healthy and Happy The Hague’, which aims to change the way healthcare/social services are provided. Two intertwined research projects combine insights from interviews, focus group meetings and observations. The first project analyzed a variety of existing co-production initiatives in several neighborhoods; the second project involved longitudinal participatory action research on what stakeholders require to engage in co-production. The two research projects showed similarities and differences in the observed opportunities/treats/challenges. The study found that empowering citizens in their role as co-producers requires major changes in the professionals’ outlook and supporting role in the communities. It illustrates the potential of synergizing insights from healthcare governance and public administration co-production literature to benefit co-production practice.

Evaluation of New York/New York III permanent supportive housing program

In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007–2017) from the NY/NY III evaluation team, to analyze this program’s impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.

Psychosocial Measures and Outcomes Among Caregivers of Children With Tracheostomies: A Systematic Review.

Children with tracheostomies have complex medical issues that require long-term technology dependence and continuous medical care at home. Parents of tracheostomy-dependent children often assume the majority of their child's home care leading to a shift in family dynamics and a decrease in caregiver quality of life. This systematic review sought to identify instruments to measure caregiver psychosocial outcomes after their child's tracheostomy and report on the findings. A systematic review was performed using Medline, CINAHL, and EMBASE. Studies that evaluated psychosocial outcomes in caregivers of tracheostomy-dependent children were included. We screened a total of 1286 nonduplicate records to include a total of 12 studies assessing the psychosocial outcomes of parents of tracheostomy-dependent children. Fourteen instruments were identified. Caregivers reported lower quality of life when compared to other chronic caregiver groups. They experienced high degrees of stress, struggled to cope individually and as a family unit, and experienced decision regret and conflict. Findings from this review suggest a significant impact on caregiver psychosocial well-being, but few quantitative studies investigated this dynamic with measures validated in this caregiver population. This review demonstrates the need for longitudinal studies using validated tools to assess the long-term impacts and outcomes of caregivers of the tracheostomy-dependent child.

It's All About the People: Advocacy in Action.

Jeannie LeDoux, MBA, BSN, RN, CCM, CPHQ, CTT+, is a commissioner and former Chair of the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies more than 50,000 professional case managers and disability management specialists. She is also a senior clinical educator at MCG, part of Hearst Health. Her professional work includes work with diverse cultures and with special needs and complex medical issues. She also has extensive experience working with the military. Address correspondence to Jeannie LeDoux, MBA, BSN, RN, CCM, CPHQ, CTT+, Commission for Case Manager Certification, 1120 Route 73, Ste 200, Mount Laurel, NJ 08054 ([email protected]). The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Teri Treiger at: [email protected] The author reports no conflicts of interest.

Delivering Virtual Care to Patients with Cognitive Impairment within the Veterans Health Administration: Multi-level Barriers and Solutions.

Older patients with cognitive impairment, including dementia, may benefit from virtual care that increases access to geriatric specialties. Here, we identify clinician-level strategies to address the numerous barriers that reduce utilization of virtual services. We describe two innovative programs in the Veterans Health Administration that deliver geriatric medicine and geriatric psychiatry services virtually. This commentary outlines concrete strategies addressing identified barriers, including technology access, digital literacy, and ambivalence and communication challenges during video visits. Two virtual care programs (tele-geriatric psychiatry consultation; tele-dementia care) that address complex medical and mental health issues in older adults with cognitive impairment are described. The Consolidated Framework for Implementation Research (CFIR) is used to categorize the clinician-level strategies and program elements as they relate to the implementation domains and constructs. Clinicians can use education strategies prior to and during virtual care visits to facilitate access to video, optimize the virtual experience, and promote information retention. These strategies rely on aspects of the inner setting, outer setting, and characteristics of individuals. The two virtual programs vary in their intervention characteristics and the inner setting, yet both programs share similar characteristics of individuals. Key elements contributing to adoption and sustainment of these virtual care programs for patients with cognitive impairment include the relative advantage of virtual care to leverage access to specialists over alternative solutions in each setting. Other factors to consider include the importance of communication, program champions, and the role of the Veterans Health Administration.

Empirical antibiotics in the intensive care unit

Patients with complex medical and surgical issues are often admitted to the intensive care unit (ICU). In such patients, prompt administration of broad spectrum empirical antibiotics is mandatory to control the infection. Antibiotic therapy should be instituted as soon as possible after the relevant culture specimens of blood, urine, endotracheal secretions or cerebrospinal fluid are sent. Ideally, empirical antibiotic therapy should be initiated within the first hour of admission of patients with suspected sepsis in ICU. While selecting the empirical antibiotic therapy, the patient's clinical history along with the probable source of infection, previous antibiotic history and most likely pathogens according to the prevalence in the particular intensive care unit (ICU) should be taken into account. A delay in initiating empirical antibiotic therapy is associated with a higher risk of progression to severe sepsis, more days on ventilator and ultimately an adverse outcome. However, empirical therapy should be de-escalated as soon as the culture and sensitivity reports are available to the clinician.

Changes in telepractice use and perspectives among speech and language therapists in Singapore through the COVID-19 pandemic.

Much has been written about the changes in use and perspectives of telepractice among speech and language therapists (SLTs) during the global COVID-19 pandemic. However, no long-term study has been done to examine whether there is a permanent shift in attitudes towards telepractice as the world adjusts to new norms and endemic COVID-19. To compare the speech telepractice use and perspectives of SLTs at two time points of the pandemic: during and after the height of the pandemic. Two online surveys were distributed a year apart among SLTs in Singapore. The first survey was disseminated during an initial lockdown period in 2020 and the second survey was done in 2021 when Singapore was starting to reduce strict quarantine and safe-distancing regulations. These surveys were distributed via communication channels of the local speech therapy association. A total of 115 and 71 responses to the survey were collected in 2020 and 2021, respectively. Responses were captured and analysed using descriptive statistics and statistical analysis while qualitative content analysis was used to derive key themes from open-ended questions. Telepractice use across all age groups and client types peaked at the height of the pandemic. Even as lockdown measures were eased, telepractice utilization was still higher than what it was before the pandemic. Dysphagia management was the only area where SLTs reduced their use of telepractice during the stabilization phase. After more experience with telepractice during the height of the pandemic, SLTs acknowledged the benefit of being able to use a wide range of media through telepractice and were less worried about not having the resources or knowledge to set up telepractice. SLTs also reported increased confidence in providing telepractice, which was reflected in their willingness to continue to provide telepractice even after the pandemic ends. The increase in use of telepractice during this pandemic is likely to be sustained as a majority of respondents believed they would continue to provide this mode of service delivery even after the pandemic ends. However, clinicians will still have to assess for client suitability, as clients with more complex medical or behavioural issues may still require in-person therapy. Additionally, dysphagia management via telepractice will still be limited given that swallow presentations may be more variable. Lastly, although generic resources are helpful for clinicians, the long-term sustainability of telepractice can be boosted by the sharing of resources that are suitable for the local context. What is already known on this subject Current studies have examined telepractice use and perspectives of SLTs before and during the COVID-19 pandemic. Despite the evidence for the efficacy of telepractice, uptake was low due to perceived lack of training and resources. Although more clinicians provided telepractice during the pandemic, many still doubted its efficacy over in-person therapy and most studies concluded that longer term studies are required to ascertain if SLTs will continuing providing telepractice after the pandemic. What this paper adds to existing knowledge This study shows that there is a definitive shift in perspectives in favour of telepractice after the pandemic, as clinicians continued to provide telepractice across most service areas even without lockdown restrictions. The previous challenges of insufficient resources, knowledge and privacy concerns were reduced with more experience in providing telepractice. Although client suitability remained a major barrier, more clinicians saw benefits of easy access to therapy and range of resources used as benefits that they could harness from telepractice. What are the potential or actual clinical implications of this work? A majority of respondents stated that they are more confident in providing telepractice and would want to continue providing this service delivery mode after the pandemic, so more training and resources suitable for the local contexts can be provided by national associations to sustain this. More research and resources can be gathered to make telepractice more efficacious for dysphagia management and clients who may be deemed unsuitable for telepractice.

Palliative rehabilitation in end-stage renal failure

BackgroundIn end-stage chronic kidney disease (CKD), patients experience disabilities stemming from organ failure. These can be worsened by symptoms and complications of underlying cause(s), and the conditions associated with the CKD. There is a dearth of literature regarding palliative rehabilitation in end-stage CKD. Our case highlights the complex medical and rehabilitative issues that such patients face.Case presentationA 64-year-old male had end-stage CKD and declined dialysis. After sustaining a myocardial infarction, he suffered a posterior circulation stroke the following month. Whilst undergoing stroke rehabilitation, his progress was further hampered by symptoms of kidney failure. The patient underwent interdisciplinary rehabilitation for 29 days. Goal-setting was performed with the patient and family to allow contextualization to the patient’s stage of disease, beliefs and environment. Care-giver training was provided to facilitate discharge back home. He demonstrated improvements in physical endurance and function. His Functional Independence Measure score improved from 51 to 82. He outlived his prognosis of 3–6 months and demised 15 months after discharge.ConclusionsIn end-stage CKD without renal replacement therapy, rehabilitation and palliative care efforts align to enhance quality of life, in the face of unlikely cure. While palliative care provides symptom management and supportive care, rehabilitation safeguards physical endurance and ability. It is in the hope of doing so, independence and thence, self-esteem, can be maintained. Future research should explore the benefits of palliative rehabilitation in renal failure.

SIMULATION IN REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY (REI): CLOSING THE COUNSELING GAP

Simulation is a well-established, effective method of education.1 In REI, existing simulations focus on procedure based surgical2 and transfer skills.3 However, there is a gap in how to educate fellows and midlevel providers to best manage challenging patient encounters experienced during morning monitoring. Due to time limitations, these interactions are brief, but with complex medical and emotional issues that require acknowledgement and resolution.

Do Hospitals Achieving "Leader in LGBTQ Healthcare Equality" Maintain Higher Patient Scores Compared To Nonleaders?

The lesbian, gay, bisexual, transgender, and queer (LGBTQ) population deals with complex medical and behavioral issues coupled with barriers in accessing both healthcare and health insurance leading to poorer health outcomes as compared with the general population. Because this community is often overlooked in efforts to improve minority health disparities, in 2007, the Human Rights Campaign Foundation introduced the Healthcare Equality Index (HEI) for evaluating healthcare facilities' policies and practices related to the equity and inclusion of their LGBTQ patients, visitors, and employees. This study's aim was to determine whether the LGBTQ Healthcare Equality Leader institution designation advantage found by DiLeo et al (2020) has a continuing positive effect on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance. We found that patient scores for both Overall Rating and Willingness to Recommend were higher with noted improvement for HEI Leader institutions as compared with non-HEI Leader institutions over this study's 3-year period. Based on the findings of this study, it can be implied that hospitals do receive a return on their investment for achieving or maintaining the HEI Leader designation and this investment benefits all populations served by the organization inferred by their maintained higher patient experience scores.