Concurrent Care Research Articles

Too close for comfort? Attitudes of gynecologic oncologists toward caring for dying patients

Objectives: Gynecologic oncologists are frequently intimately involved in end of life care for their patients. The primary objective of this study was to assess the attitudes of gynecologic oncology providers toward palliative care for advanced cancer patients. Methods: SGO members categorized as gynecologic oncologists or medical oncologists were surveyed via an anonymous RedCap online survey. The survey consisted of basic demographic information and a survey regarding attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer. Descriptive statistics were calculated. Associations between provider sociodemographic characteristics and responses were analyzed using linear regression. Results: 1200 members received the survey and 108 (9%) completed the survey. The majority of respondents were female (69.4%) and White (82.4%). Most described their practice as academic (64.8%) and in an urban environment (71.3%). The majority (95.4%) had palliative care providers at their institution and stated they were often directly involved with discussing end of life care preferences with their patients (88%). The majority believed that oncologists should coordinate the care of cancer patients at all stages of disease, including end of life care (66%). Most believed that all advanced cancer patients should receive concurrent palliative care along with anti-tumor therapies (81%). The majority derived satisfaction from their work managing patients with advanced cancer (83%). Twenty percent stated that managing patients with advanced cancer and dying patients depresses them. Twenty-seven percent stated they felt emotionally burned out by having to deal with too many deaths. There were no significant associations between sociodemographic characteristics and responses. Conclusions: The majority of gynecologic oncologists believe that palliative care should occur in conjunction with anti-tumor therapies. Most gynecologic oncologists are involved in the care of their patients at the end of life and derive satisfaction from their work. This close connection with patients as they transition to the end of life may take a toll on providers. Nearly a third of respondents felt emotionally burned out by managing death. One in five surveyed felt depressed by end of life care work.

Trends and guideline-related changes in provision of palliative care in older women with gynecologic malignancies

Objectives: To determine if the rate of palliative care consultation (PCC) in older women with gynecologic malignancies increased after the publication of the American Society of Clinical Oncology guidelines in 2012. Additionally, to identify factors associated with utilization of palliative care. Methods: We included women ≥ 66 years with stage III-IV, ovarian, uterine, cervix or vulvar cancer diagnosed in 2011 and 2013 in the linked Surveillance Epidemiology, End Results (SEER)- Medicare database. Patient demographic, cancer, and treatment characteristics were extracted. We evaluated PCC within 365 days of diagnosis (PCC365) and within 56 days of diagnosis (PCC56). We used a multivariable Cox proportional hazard model to compare PCC in 2011 versus 2013. We identified factors associated with PCC in women diagnosed with cancer in 2013 using a univariate and multivariable logistic regression. Results: We identified 2,643 women diagnosed with advanced gynecologic malignancies. 56% of patients had ovarian cancer, 34% uterine cancer, 8% cervical cancer and 3% vulvar cancer. In 2011, 12% of women had a PCC365 versus 14% in 2013. Taking into account multiple factors, women diagnosed in 2013 were more likely to have a PCC365 than women diagnosed in 2011 (adjusted HR 1.36, 95% CI 1.09, 1.71). Women diagnosed with an advanced gynecologic malignancy in 2013 who were Black versus White (adjusted HR 1.72, 95% CI 1.06, 2.78), had a Charlson comorbidity index of 3 versus 0 (adjusted HR 1.81, 95% CI 1.17, 2.80) or stage IV verus stage III cancer (adjusted HR 1.79, 95% CI 1.26, 2.54) were more likely to receive PCC365. Women who received initial cancer treatment with surgery were less likely to receive PCC365 (adjusted HR 0.52, 95% CI 0.35, 0.78). Conclusions: The rate of palliative care in women with advanced gynecologic malignancies increased slightly, although significantly, between 2011 and 2013 but the absolute rate remains low despite changes in recommendations. New innovations are needed to increase concurrent palliative care with standard oncology treatment for woman with advanced gynecologic malignancies.

Opportunities for dietitians to promote a healthy dietary intake in pregnant women with a low socio-economic status within antenatal care practices in the Netherlands: a qualitative study

BackgroundA healthy dietary intake during pregnancy is important for maternal and child health. However, pregnant women with a low socio-economic status often fail to meet dietary guidelines and requirements for healthy nutrition. Dietitians may play an important role in providing nutritional advice during pregnancy because midwives often experience a lack of nutritional knowledge, time and skills to provide adequate advice. However, there is limited research on the support that dietitians can offer in antenatal care practices for pregnant women. Therefore, this study aims to explore the opportunities for dietitians to support pregnant women with a low socio-economic status in concurrent antenatal care practices in the Netherlands.MethodsIn-depth interviews were conducted with 14 pregnant women with a low socio-economic status and 13 dietitians to identify barriers for healthy eating for pregnant women and the associated opportunities for dietitians to support these women in making healthy dietary changes.ResultsFour opportunities for dietitians to support pregnant women in making dietary changes could be discerned: (1) creating awareness of healthy and unhealthy eating patterns, (2) providing reliable and personally relevant information, (3) help identifying barriers and solutions for healthy eating and (4) making healthy eating manageable. Dietitians indicated that supporting pregnant women with a low socio-economic status in consuming a healthy diet requires the investment of sufficient time, effort and money.ConclusionsDietitians are trained and well-equipped to provide extensive support to pregnant women to promote a healthy dietary intake, especially when the complex interplay of barriers that pregnant women with a low socio-economic status experience for healthy eating needs to be addressed. In addition, there is a strong need for strengthening the collaboration between dietitians and midwives because midwives are the primary care provider for pregnant women in the Netherlands, but they often lack sufficient opportunities to provide adequate nutrition support. Strengthening this collaboration could promote that nutrition becomes a recurring and standard topic in antenatal care.

Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer.

To describe palliative, concurrent, and hospice care in pediatric oncology in the United States (US), we present a clinical scenario illustrating palliative and hospice care, including eligibility for concurrent care, insurance coverage and billing, barriers to accessing quality pediatric palliative and hospice care, and implications for oncology nursing practice. Peer-reviewed articles, clinical practice guidelines, professional organizations, and expert clinical opinion examining pediatric oncology, palliative care, and hospice care. Understanding the goals of palliative and hospice care and the differences between them is important in providing holistic, goal-directed care. Oncology nurses play a pivotal role in supporting the goals of pediatric palliative care and hospice care and in educating patients and their families. Nurses form trusting relationships with pediatric oncology patients and their families and are in a position to advocate for best palliative care practices as disease progresses to end of life, including when appropriate concurrent care or hospice.

Patterns of Health Care Services During Pediatric Concurrent Hospice Care: A National Study.

Children at end of life have unique and complex care needs. Although there is increasing evidence about pediatric concurrent hospice care, the health care services received while in hospice have not received sufficient attention. To examine the health care services, unique clusters of health care services, and characteristics of the children in the clusters. Multiple data sources were used including national Medicaid claims data. Children under 21years in pediatric concurrent hospice care were included. Using Medicaid categories assigned to claims, health care services were distributed across 20 categories. Latent class analysis was used to identify clusters of health care services. Demographic profiles of the clusters were created. The 6,243 children in the study generated approximately 500,0000 non-hospice, health care service claims while enrolled in hospice care. We identified 3 unique classes of health care services use: low (61.1%), moderate (18.1%), and high (20.8%) intensity. The children in the 3 classes exhibited unique demographic profiles. Health care services cluster together in unique fashion with distinct patterns among children in concurrent hospice care. The findings suggest that concurrent hospice care is not a 1-size-fit all solution for children. Concurrent hospice care may be customized and require attention to care coordination to ensure high-quality care.

Patterns of integrating palliative care into standard oncology in an early ESMO designated center: a 10-year experience

BackgroundIntegration of specialist palliative care (PC) into standard oncology care is recommended. This study investigated how integration at the Cantonal Hospital St. Gallen (KSSG) was manifested 10 years after initial accreditation as a European Society for Medical Oncology (ESMO) Designated Center (ESMO-DC) of Integrated Oncology and Palliative Care.MethodsA chart review covering the years 2006-2009 and 2016 was carried out in patients with an incurable malignancy receiving PC. Visual graphic analysis was utilized to identify patterns of integration of PC into oncology based on the number and nature of medical consultations recorded for both specialties. A follow-up cohort collected 10 years later was analyzed and changes in patterns of integrating specialist PC into oncology were compared.ResultsThree hundred and forty-five patients from 2006 to 2009 and 64 patients from 2016 were included into analyses. Four distinct patterns were identified using visual graphic analysis. The ‘specialist PC-led pattern’ (44.9%) and the ‘oncology-led pattern’ (20.3%) represent disciplines that took primary responsibility for managing patients, with occasional and limited involvement from other disciplines. Patients in the ‘concurrent integrated care pattern’ (18.3%) had medical consultations that frequently bounced between specialist PC and oncology. In the ‘segmented integrated care pattern’ (16.5%), patients had sequences of continuous consultations provided by one discipline before alternating to a stretch of consultations provided by the other specialty. In the 2016 follow-up, while the ‘oncology-led pattern’ occurred significantly less frequently relative to the ‘specialist PC-led pattern’ and the ‘segmented integrated care pattern’, the ‘concurrent integrated care pattern’ emerged more frequently when compared with the 2006-2009 follow-up.ConclusionThe ‘specialist PC-led pattern’ was the most prominent pattern in this data. The 2016 follow-up showed that a growing number of patients received a collaborative pattern of care, indicating that integration of specialist PC into standard oncology can manifest as either segmented or concurrent care pathways. Our data suggest a closer, more dynamic and flexible collaboration between oncology and specialist PC early in the disease course of patients with advanced cancer and concurrent with active treatment.

Palliative care in patients with left ventricular assist devices: systematic review

HintergrundBei terminal herzinsuffizienten Patienten gewinnt die Implantation von Linksherzunterstützungssystemen (LVAD) als Therapieoption zunehmend an Bedeutung. Diese Systeme werden als Überbrückung bis zu einer Herztransplantation (BTT) oder als definitive Therapie (DT) eingesetzt. Sie können die Lebensqualität verbessern und die Lebenszeit verlängern. Trotzdem bleibt die Prognose besonders bei DT oder bei Wechsel von BTT zu DT mit Blick auf die Lebenszeit und auftretende Komplikationen ungünstig. Bisher ist ungeklärt, ob eine LVAD-Implantation eine Indikation für eine frühzeitige Integration von Palliativmedizin darstellt.Ziel der ArbeitErfassung der aktuellen Studienlage über den Einfluss einer palliativmedizinischen Behandlung bei LVAD-Patienten.Material und MethodenIm Mai 2020 wurde eine systematische Literaturrecherche in 6 verschiedenen Datenbanken durchgeführt.ErgebnisseVon den 491 Treffern der Literaturrecherche wurden 21 Arbeiten in diese Übersichtsarbeit eingeschlossen. Durch die frühzeitige Integration der Palliativmedizin vor LVAD-Implantation erhöhte sich die Anzahl der Patienten mit vorausschauender Versorgungsplanung und Vorsorgeinstrumenten. Außerdem zeigte sich ein positiver Einfluss auf das familiäre Umfeld, das Symptommanagement und die Umstände des Versterbens. Es gibt verschiedene Formate für die Integration palliativmedizinischer Konzepte in die LVAD-Therapie.DiskussionDie frühzeitige und kontinuierliche Einbindung der Palliativmedizin im Verlauf einer LVAD-Therapie kann die Behandlungsqualität verbessern. Die Ausarbeitung von spezifischen Handlungsempfehlungen ist in Abhängigkeit vom Therapieziel (BTT oder DT) sinnvoll. Empfohlen werden Schulungen für Palliativmediziner und LVAD-Spezialisten.

Poor family relationships in adolescence as a risk factor of in-patient somatic care across the life course: Findings from a 1953 cohort.

BackgroundPrior research has shown that poor family relations during upbringing have long-term detrimental effects on mental health. Few previous studies have, however, focused on somatic health outcomes and studies rarely cover the life span until retirement age. The aims of the current study were, firstly, to examine the association between poor family relationships in adolescence and in-patient somatic care across the life course whilst adjusting for confounders at baseline and concurrent psychiatric in-patient care; and secondly, to compare the risks of somatic and psychiatric in-patient care across the life course.MethodsProspective data from the Stockholm Birth Cohort study were used, with 2636 participants born in 1953 who were followed up until 2016. Information on family relationships was collected from the participants’ mothers in 1968. Annual information on in-patient somatic and psychiatric care was retrieved from official register data from 1969 to 2016.ResultsPoisson regressions showed that poor family relationships in adolescence were associated with an increased risk of in-patient somatic care in mid- and especially in late adulthood (ages 44–53 and 54–63 years), even when controlling for the co-occurrence of psychiatric illness and a range of childhood conditions. No statistically significant association was observed in early adulthood (ages 16–43 years), when controlling for confounders. These findings are in sharp contrast to the analyses of inpatient psychiatric care, according to which the association with poor family relations was strongest in early adulthood and thereafter attenuated across the life course.ConclusionPoor family relationships in adolescence are associated with an increased risk of severe consequences for somatic health lasting to late adulthood even when controlling for confounders including in-patient psychiatric care, emphasising the potentially important role of early interventions.

A Comparison of Young Adults With and Without Cancer in Concurrent Hospice Care: Implications for Transitioning to Adult Health Care.

Purpose: Concurrent hospice care provides important end-of-life care for youth under 21 years. Those nearing 21 years must decide whether to shift to adult hospice or leave hospice for life-prolonging care. This decision may be challenging for young adults with cancer, given the intensity of oncology care. Yet, little is known about their needs. We compared young adults with and without cancer in concurrent hospice care. Methods: Retrospective comparative design used data from 2011 to 2013 U.S. Medicaid data files. Decedents were included if they were 20 years of age, enrolled in Medicaid hospice care, and used nonhospice medical services on the same day as hospice care based on their Medicaid claims activity dates. Results: Among 226 decedents, 21% had cancer; more than half were female (60.6%), Caucasian (53.5%), non-Hispanic (77.4%), urban dwelling (58%), and had mental/behavioral disorder (53%). Young adults with cancer were more often non-Caucasian (68.7% vs. 40.4%), technology dependent (47.9% vs. 24.2%), had comorbidities (83.3% vs. 30.3%), and lived in rural (58.3% vs. 37.6%), southern (41.7% vs. 20.8%) areas versus peers without cancer. Those with cancer had significantly fewer live discharges from hospice (5.7 vs. 17.3) and sought treatment for symptoms more often from nonhospice providers (35.4% vs. 14.0%). Conclusions: Young adults in concurrent hospice experience medical complexity, even at end-of-life. Understanding care accessed at 20 years helps providers guide young adults and families considering options in adult-focused care. Clinical and demographic differences among those with and without cancer in concurrent care highlight needs for research exploring racial and geographic equity.

Factor VIII Inhibitor Bypassing Activity (FEIBA) Reversal for Apixaban and Rivaroxaban in Patients With Acute Intracranial and Nonintracranial Hemorrhage.

The clinical use of factor VIII inhibitor bypassing activity (FEIBA) for factor Xa (FXa) inhibitor reversal is derived from small studies with notable variation in patient eligibility for use, dosage regimens, concurrent supportive care, and outcome measures. Consequently, additional effectiveness and safety data are warranted to expand the literature evaluating FEIBA for FXa inhibitor reversal. This study sought to determine the incidence of observed effective hemostasis within 24 hours of post-FEIBA® administration as well as in-hospital and 30-day post-discharge incidences of thromboembolic event (TEE) and mortality between apixaban and rivaroxaban in the intracranial hemorrhage (ICH) and non-ICH populations. This case series evaluated patients between January 1, 2014 through July 1, 2019 who received at least one FEIBA® dose for apixaban or rivaroxaban reversal secondary to acute ICH or non-ICH. Patient demographics, FEIBA® dosages, adjunct treatments, effectiveness, and safety outcomes were retrospectively collected from electronic medical record review. Modified hemostasis outcomes, adapted from criteria previously published by Sarode et al., TEE, and mortality between apixaban and rivaroxaban in the ICH and non-ICH populations were evaluated. Among the 104 patients evaluated, 62 received apixaban and 42 rivaroxaban. Thirty apixaban and 25 rivaroxaban users experienced ICH, whereas 32 apixaban and 17 rivaroxaban users experienced non-ICH. Among the combined ICH and non-ICH populations, effective hemostasis occurred in 89%, TEE in 8%, and mortality in 13%. No statistically significant differences were observed within ICH and non-ICH populations receiving apixaban or rivaroxaban regarding effective hemostasis, TEE, or mortality. The combined ICH and non-ICH overall rates of effective hemostasis, TEE, and mortality were comparable to preexisting studies of FEIBA for factor Xa inhibitor reversal. The limitations inherent to the study design warrant a randomized controlled trial with an active comparator to confirm these observations.

Examining the role of specialist palliative care in geriatric care to inform collaborations: a survey on the knowledge, practice and attitudes of geriatricians in providing palliative care.

The global population is ageing, and rates of multimorbidity and chronic illness are rapidly rising. Given specialist palliative care has been shown to improve overall care and reduce health care costs, how best to provide this care to older people is internationally significant. To examine the knowledge, attitudes and practices of geriatricians in providing palliative care and working with specialist palliative care services. We also aimed to capture self-reported barriers, confidence and satisfaction in providing palliative care. A prospective cross-sectional study surveying Australasian geriatricians was conducted. This was a voluntary anonymous online survey, distributed to all full members of the Australian and New Zealand Society of Geriatric Medicine. A total of 168 completed responses were received; 58.3% were female and 36.6% had over 20years of clinical experience. Most geriatricians (85%) reported caring for patients in their last 12 months of life represented a substantial aspect or most of their practice. Geriatricians overwhelmingly believed they should coordinate care (84%) and derived satisfaction from providing palliative care (95%). The majority (69%) believed all patients with advanced illness should receive concurrent specialist palliative care. Regarding knowledge, participants scored an average of 13.5 correct answers out of 18 in a Modified Palliative Care Knowledge Test. Geriatricians find reward in providing generalist palliative care to their patients; however, potential exists for improved collaborations with specialist palliative care services. An evidence base for geriatric patients who benefit most from specialist palliative care services is needed to improve resourcing, collaborative practice and ultimately palliative care delivery.

Medical complexity and concurrent hospice care: A national study of Medicaid children from 2011 to 2013.

Pediatric hospice is a comprehensive model of care for medically complex children at end of life. The Affordable Care Act changed regulatory requirements for pediatric Medicaid enrollees to allow for enrollment into hospice services while still receiving life-prolonging therapy. There are gaps in understanding factors associated with pediatric concurrent hospice care use. The objectives were to examine the prevalence of concurrent hospice care overtime and investigated the relationship between medical complexity and concurrent hospice care among Medicaid children. We used national Medicaid data and included children less than 21 years with an admission to hospice care. Medical complexity was defined with four criteria (i.e., chronic conditions, functional limitations, high health care use and substantial needs). Using multivariate logistic regression, we evaluated the influence of medical complexity on concurrent hospice care use, while controlling for demographic, hospice, and community characteristics. Thirty-four percent of the study sample used concurrent hospice care. Medical complexity was unrelated to concurrent hospice care. However, the four individual criteria were associated. A complex chronic condition was negatively related to concurrent hospice care, whereas technology dependence, multiple complex chronic conditions, and mental/behavioral disorders were positively associated to concurrent care use. These findings suggest that concurrent hospice care may be important for a subset of medically complex children with functional limitations, high health utilization, and substantial needs at end of life.

POS-274 A RANDOMIZED TRIAL OF EFFECT OF CHOLECALCIFEROL SUPPLEMENTATION ON CVD, INFLAMMATION AND BONE METABOLISM MARKERS IN CKD: DESIGN AND METHODS

Short term studies have shown that vitamin D supplementation may favorably influence vascular function, inflammation and bone metabolism in CKD. There are no long-term studies that have looked at hard clinical end points in this regard. This study will explore the effect of cholecalciferol supplementation on cardiovascular disease, markers of inflammation and bone metabolism in CKD. We present the design and results of initial pilot phase of the proposed clinical trial. The study is a multicenter, prospective, randomized, placebo-controlled, double blind trial in two parallel groups. After a run-in-phase of 2 weeks, the enrolled patients are randomized in 1:1 ratio to receive cholecalciferol or matching placebo. Cholecalciferol is given at the dosage of 60,000 IU/2 weeks. The patients will be followed up at 3, 6, 9, 12, 24 and 36 months after enrolment. All clinical events and hospitalizations during the course of the study will be recorded. Primary outcome is a composite of Major Adverse Cardiovascular Events (MACE) that includes new onset heart failure, coronary heart disease, peripheral vascular disease, cerebrovascular accident, any coronary or peripheral arterial revascularization procedure and death due to cardiovascular disease. Secondary outcomes include all-cause mortality, need for renal replacement therapy, change in hsCRP and IL-6, change in iPTH, FGF-23, bone specific alkaline phosphatase and CTX-1. The feasibility phase is currently being run at PGIMER, Chandigarh, India. Serum levels of 25(OH)D, calcium, and iPTH will be checked at every scheduled follow up visit. The concurrent clinical care will continue as per prevailing standards of care. We plan to enroll 1244 patients (622 in each group) across 11 centers. The trial is registered at Clinical Trials Registry of India (CTRI/2019/05/019211). Till date, 340 patients have been screened for enrolment. 61 have been successfully randomized; their baseline samples have been collected and stored, and drugs have been dispensed to them. Till now, 30 patients have completed their 3 months follow up with 6 subjects having completed 6 months follow up as well. Figure 1 depicts the conduct of study so far. Table 1 shows the baseline characteristics of the study population. Though delayed due to ongoing COVID 19, the study has fulfilled the pre-specified feasibility criteria of recruitment of >50% eligible subjects (achieved 94.9%), recruitment rate of ≥7 subjects per month (achieved 8.7 subjects per month) and ≤25% overall subject withdrawal rate (subject withdrawal rate 10.63%). Tabled 1Baseline characteristicsMean (SD) or FrequencySex (M/F)M- 35/ F- 26Age (years)52.1 (11.3)Hemoglobin (g/dl)11.5 (1.8)S creatinine (mg/dL)2.7 (1.2)eGFR (CKD-EPI)27.5 (11.2)Blood urea (mg/dL)77.4 (37.5)S Calcium (mg/dL)9.0 (0.8)S inorganic phosphorus (mg/dL)3.9 (0.9)S uric acid (mg/dL)7.2 (1.8)S alkaline phosphatase (U/L)108.2 (30.1)S total cholesterol (mg/dL)149.4 (40.3)S triglycerides (mg/dL)140.6 (72.1)S LDL-C (mg/dL)86.2 (37.4)S HDL-C (mg/dL)46.3 (13.4)Spot urine protein (mg/dL)107.3 (138.3)Spot urine creatinine (mg/dL)79.6 (57.1)S 25(OH)D (ng/ml)28.8 (11.4)S iPTH (pg/ml)216.4 (150.7) Open table in a new tab The study has achieved pre specified feasibility criteria. In the multi-centric phase, the study will set the stage for testing a relatively inexpensive intervention in the form of vitamin D supplementation for CVD in CKD.

A National Profile of Children Receiving Pediatric Concurrent Hospice Care, 2011 to 2013.

When the 2010 Patient Protection and Affordable Care Act (ACA) was passed, it fundamentally changed end-of-life care for children. Concurrent Care for Children (ACA, section 2302) enables Medicaid/Children's Health Insurance Program children with a prognosis of 6 months to live to use hospice care while continuing treatment for their terminal illness. Although ACA, section 2302, was enacted a decade ago, little is known about these children. The purpose of this study was to generate the first-ever national profile of children enrolled in concurrent hospice care. Using data from multiple sources, including US Medicaid data files from 2011 to 2013, a descriptive analysis of the demographic, community, hospice, and clinical characteristics of children receiving concurrent hospice care was conducted. The analysis revealed that the national sample was extremely medically complex, even for children at end of life. They received care within a complicated system involving primary care providers, hospices, and hospitals. These findings have clinical and care coordination implications for hospice nurses.

Medical Complications and Prognostic Factors for Medically Unstable Conditions During Acute Inpatient Cancer Rehabilitation.

Acute inpatient rehabilitation provides concurrent medical care and intensive rehabilitation. We sought to describe the nature of types of medical complications and to identify the more frequent types of medical complications management in patients with cancer undergoing acute inpatient rehabilitation. We reviewed the records of all consecutive patients admitted to acute inpatient rehabilitation from September 1, 2017, through February 28, 2018. Presenting problem noted to be a significant change in medical status using the Centers for Medicare & Medicaid Services' Evaluation and Management Service Guide was defined as a medical complication. We recorded demographic and clinical characteristics. Multivariable logistic regression analysis was performed to assess prognostic factors for returning to acute care. Among 165 evaluable patients, 158 (96%) had at least one medical complication, and 31 (19%) had an unplanned return to acute care. After excluding three patients who had planned return to acute care, there was a cohort of 162 patients and the most common medical complication categories were electrolyte abnormalities 81 (50%), musculoskeletal 70 (43%), genitourinary or renal 61 (38%), hematologic 58 (36%), and cardiovascular problems 46 (28%). Multivariable analysis showed that tachycardia (odds ratio [OR], 7.83; 95% CI, 2.23 to 27.54; P = .001) and weekly or more frequent RBC transfusions (OR, 5.23; 95% CI, 1.39 to 19.64; P = .014) were independently associated with unplanned return to acute care. A high frequency and wide range of medical complications and interventions occur in patients with cancer undergoing acute inpatient rehabilitation. Close monitoring and expertise are needed for this patient population.

Louisiana Pediatric Hospice Concurrent Care: Rewriting Culture and Language

Louisiana Pediatric Hospice Concurrent Care: Rewriting Culture and Language

Cost Analysis of Pediatric Concurrent Care: Commercial vs Medicaid Payer

Cost Analysis of Pediatric Concurrent Care: Commercial vs Medicaid Payer

Evaluation of Clinical Outcome in Traumatic Facial Nerve Paralysis.

Introduction The facial nerve is the most commonly paralyzed nerve in the human body, resulting in far-reaching functional, aesthetic and emotional concerns to the patient. Objective Evaluation of the clinical outcome of 47 patients with traumatic facial nerve paralyses, with respect to clinical recovery and audiological sequelae. Methods A descriptive longitudinal study was conducted over 24 months between January 2017 and December 2018 at a tertiary center with detailed clinical, topodiagnostic, audiometric and radiological evaluation and regular follow-up after discharge. Results Road traffic accidents constituted 82.98% of the trauma cases, out of which 76.60% were found to be under the influence of alcohol. Delayed facial paralysis was observed in 76.60% cases. Temporal bone fracture was reported in 89.36%, with otic capsule (OC) sparing fractures forming 91.49% of the cases. Topologically, the injury was mostly at the suprachordal region around the second genu. The majority of the patients (65%) attained full recovery of facial nerve function with conservative medical management. Audiometrically, 77.27% of the patients had hearing loss at the time of presentation, of which 64.71% were conductive in nature; 51.22% attained normal hearing at follow-up visits.Conclusion Early initiation of steroid therapy, concurrent eye care and physiotherapy are the cornerstones in the management of traumatic facial nerve paralysis.

Engaging community health workers, technology, and youth in the COVID-19 response with concurrent critical care capacity building: A protocol for an integrated community and health system intervention to reduce mortality related to COVID-19 infection in Western Kenya

Globally, the number of COVID-19 infections is approaching 63 million; more than 1 million individuals have lost their lives. In Kenya, the number of infections has surpassed 80,000 and 1469 people have lost their lives. In Kenya, the community health strategy has been used to deliver essential health services since 2007. Furthermore, the population in Kenya is young (the median age is 21 years old) and Kenya is recognized as a technology hub in the East African region. Community-based health care, youth, and technology, are assets within the Kenyan context that can be leveraged to respond to the COVID-19 pandemic with concurrent strengthening of the critical care capacity at the health system level. This is a quasi-experimental study with quantitative and qualitative methods of data collection to complete a baseline assessment of community health unit and health facility service readiness in the study site of Siaya County in western Kenya. Following the baseline assessment, service ready community health units and health facilities with oxygen capacity will form intervention groups. At the community level, the intervention will consist of training youth, community health assistants and community health workers in screening, case detection, prevention, management and referral of COVID-19 cases with maintenance of essential health services. The community intervention will be enhanced by youth and use of digital tools. At the health facility level, the intervention will consist of training health care workers in basic critical care and caring for severe COVID-19 patients with maintenance of essential health services. The primary outcome measure will be mortality related to COVID-19 infection both at community and health facility levels. This study would be the first study to evaluate the effectiveness of an integrated approach in preparing for and implementing a robust pandemic response. Registration: ClinicalTrials.gov ID NCT04501458; registered on 6 August 2020.

Cost of Pediatric Concurrent Hospice Care: An Economic Analysis of Relevant Cost Components, Review of the Literature, and Case Illustration.

Background: Concurrent care enables seriously ill pediatric Medicaid and Children's Health Insurance Program (CHIP) beneficiaries to continue curative treatments along with the supportive services usually associated with hospice care. Although a few studies have examined pediatric concurrent care, none has explored the economics of this care delivery approach for medically complex children. Objective: The purpose of this study was to identify the cost components relevant for an economic analysis of pediatric concurrent hospice care and demonstrate the use of the cost components in an economic case illustration. Methods: A scoping review of the hospice cost literature was conducted to identify article focused on hospice costs that were published in the journal literature from 2000 to 2019. A preliminary economic analysis was also conducted using a cost-minimization approach with data from a large mid-Atlantic pediatric hospice provider. We compared costs between concurrent versus standard hospice care for children. Results: Fifteen hospice cost articles were identified and no article on concurrent care costs. Most articles in the scoping review focused on hospice personnel costs, followed by supplies/equipment, and other. Personnel and costs were higher for standard hospice children compared with concurrent care, whereas concurrent care children had higher supplies/equipment costs. Conclusions: Identifying cost components are critical to economic analysis of pediatric concurrent care. These findings provide preliminary evidence about the difference in costs between concurrent and standard hospice care for children.