High Health Care Research Articles

Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing low back pain in Alberta, Canada.

Low back pain (LBP) is a common condition causing disability and high healthcare costs. Alberta faces challenges with unnecessary referrals to specialists and long wait times. A province-wide standardized clinical care pathway based on evidence-based best practices can improve efficiency, reduce wait times, and enhance patient outcomes. Implementing such pathways has shown success in other areas of healthcare in Alberta. This study developed a clinical decision-making pathway to standardize care and minimize uncertainty in assessment, diagnosis, and management. A systematic rapid review identified existing tools and evidence that could support a comprehensive LBP clinical decision-making tool. Forty-seven healthcare professionals participated in four rounds of a modified Delphi approach to reach consensus on the assessment, diagnosis, and management of patients presenting to primary care with LBP in Alberta, Canada. This project was a collaborative effort between Alberta Health Services' Bone and Joint Health Strategic Clinical Network (BJHSCN) and the Alberta Bone and Joint Health Institute (ABJHI). A province-wide expert panel consisting of professionals from different health disciplines and regions collaborated to develop an LBP clinical decision-making tool. This tool presents clinical care pathways for acute, subacute, and chronic LBP. It also provides guidance for history-taking, physical examination, patient education, and management. This clinical decision-making tool will help to standardize care, provide guidance on the diagnosis and management of LBP, and assist in clinical decision-making for primary care providers in both public and private sectors.

P1188 Epidemiology and direct healthcare costs of patients with Inflammatory Bowel Disease (IBD) in an Asian cohort in the first year following diagnosis

Abstract Background Inflammatory Bowel Disease (IBD) is a chronic condition requiring multi-disciplinary care with significant investigation and treatment burden. Indeed, the global treatment market has exceeded US$ 20 billion and is expected to exceed 27 billion in 2030. We aim to study the epidemiology and direct healthcare costs of newly diagnosed IBD patients in their first year of diagnosis in Singapore General Hospital (SGH) and identify factors associated with high direct healthcare costs. Methods The study included patients identified from a prospectively maintained IBD registry of SGH. We enrolled patients newly diagnosed with IBD from 2015 to 2022. Patients who received prior treatment or investigation at other institutions were excluded. Data on clinical characteristics and direct costs (investigations, medications, clinic visits, hospitalisations and surgeries) were collected. Results A total of 199 patients were enrolled across 2015 - 2022. 96 patients had Ulcerative Colitis (UC) and 103 had Crohn’s disease (CD) (Table 1). There were 26 (20-28) new cases of IBD diagnosed at SGH yearly. Direct healthcare costs of patients in their first year of diagnosis remained steady with an overall 7.1% change in total expenditure from 2015 through 2022. A drop in expenditure happened in 2020 and 2021 due to COVID outbreak and country lockdown. (Fig 1A) The mean cost per patient-year (PPY) was US$12995 for CD US$104345 for UC. 10 (8-11) patients required admission within the first year of diagnosis, with a mean hospitalisation cost PPY of $269717 (± 73771). Overall, inpatient costs accounted for 39.3 % (IQR 34.8 - 44) of yearly expenditure (Fig 1B). A median of 16.7% (14.6-22.1) of patients were started on biologics within the first year of diagnosis. Patients with CD had significantly greater mean expenditure than those with UC on imaging ($1036 vs $328, p = 0.001) and biologics ($1535 vs $603, p = 0.033). Patients above the 75th percentile of mean cost PPY were defined as having high healthcare cost. This was $12265 and $15957 for UC and CD respectively. Factors associated with high costs were hospitalisation (p < 0.001), biologics (p = 0.001), surgery (p = 0.01) for both UC and CD. UC extent, CD behaviour, history of smoking and age> 40 were not predictive of high costs. Conclusion Patients with CD have greater expenditure compared to patients with UC in the first year following diagnosis. Biologics use, surgery and hospitalisation are significant drivers of costs. The proportion of newly diagnosed patients requiring admission and their corresponding costs have remained consistent during our period of study. These findings encourage early identification of at-risk patients with institution of treatment to minimise hospitalisation and surgical burden.

Esrar Kullanım Bozukluğu Tedavisinde Kullanılan İnternet Tabanlı Psikososyal Müdahale Programları: Bu Programların Etkinlikleri ve Sınırlılıkları

This review focuses on the internet-based psychosocial intervention methods used in the treatment of cannabis use disorder, reviewing their effectiveness and limitations in light of the available information. Cannabis use disorder contributes to both physical and mental health issues, as well as high healthcare costs. In recent years, various internet-based psychosocial interventions have been developed for treating this condition. These interventions can be categorized into three main groups: self-help and educational programs, mobile applications and gamified interventions, and peer support with community-based platforms. Studies indicate that these internet-based psychosocial interventions could be an effective alternative for the treatment of cannabis use disorder. Their strengths include the potential to reduce the frequency and amount of cannabis use, their flexible and accessible nature, and the ability to reach a broad user base. However, limitations such as technological access and digital literacy issues, data security and privacy concerns, discrepancies in demographic and cultural diversity, and challenges in long-term follow-up and sustainability are evident, particularly in cases of severe psychological disorders or situations requiring immediate intervention. While the results of relevant research are promising, there have been a limited number of randomized controlled trials conducted. Keywords: Cannabis, Cannabis use disorder, Internet-based psychosocial interventions.

Real world outcomes, healthcare utilisation and costs of Alzheimer's disease in England

BackgroundEvidence on health and social care resource utilisation and associated costs, and how this varies across people with Alzheimer's disease (AD) dementia is limited. MethodsRetrospective cohort, using the Discover dataset, which includes linked health and social care records for approximately 2.5 million people in North-West London. Individuals were followed up from the latter of 2010 or from diagnosis of AD dementia (index) up to 2019. Outcomes were overall survival, care home admission, health and social care utilisation and associated costs, and cardiovascular outcomes. Variation was explored in subpopulations and by stratifying by cost quintile. Generalised linear modelling was used to estimate the association between clinical and demographic characteristics and healthcare costs. ResultsThe cohort included 18,116 people diagnosed with AD dementia whose mean age at index was 81 years, 62 % were female and 65 % were of white ethnicity. Median survival from index was 4.9 years (95 %CI: 4.8–5.0). Mean healthcare costs were £4,548(£4,491–£4,604) per person year(ppy). Healthcare costs for the 48 % who used social care were £5,433ppy(£5,353–£5,514) and social care costs were £24,374ppy(£24,372–£24,376). In the overall cohort costs in the highest cost quintile were £13,665ppy(£13,420–£13,911), of which 70 % was from inpatient hospitalisation. Subpopulations admitted to care home (£7,535 £7,362–£7,709), with cardiovascular disease (£6,106;£5,990–£6,222) and with type 2 diabetes (£6,049;£5,901–£6,198) accrued the highest healthcare costs. Factors most strongly associated with cost were dying during follow up (+£2,224;£2,010–£2,493), being frail (+£1,246;£1,051–£1,440) and prior stroke (+£1,207;£908–£1,507). ConclusionCharacteristics of individuals with high healthcare costs include requirement for social care and cardiometabolic comorbidities. Identifying individuals early in their disease course may improve health outcomes and reduce the cost of AD dementia in later life.

Novel Insights in Venous Thromboembolism Risk Assessment Methods in Ambulatory Cancer Patients: From the Guidelines to Clinical Practice.

Many cancer patients will experience venous thromboembolism (VTE) at some stage, with the highest rate in the initial period following diagnosis. Novel cancer therapies may further enhance the risk. VTE in a cancer setting is associated with poor prognostic, a decreased quality of life, and high healthcare costs. If thromboprophylaxis in hospitalized cancer patients and perioperative settings is widely accepted in clinical practice and supported by the guidelines, it is not the same situation in ambulatory cancer patient settings. The guidelines do not recommend primary thromboprophylaxis, except in high-risk cases. However, nowadays, risk stratification is still challenging, although many tools have been developed. The Khrorana score remains the most used method, but it has many limits. This narrative review aims to present the current relevant knowledge of VTE risk assessment in ambulatory cancer patients, starting from the guideline recommendations and continuing with the specific risk assessment methods and machine learning models approaches. Biomarkers, genetic, and clinical features were tested alone or in groups. Old and new models used in VTE risk assessment are exposed, underlining their clinical utility. Imaging and biomolecular approaches to VTE screening of outpatients with cancer are also presented, which could help clinical decisions.

Assessment of quality of life, job insecurity and work ability among nurses, working either under temporary or permanent terms.

Aim of this study was to assess and compare health, quality of life, well-being, job satisfaction and job insecurity between nurses, in a tertiary hospital in Greece, working either under permanent or temporary contract. In this cross-sectional study, consecutively recruited nurses answered a structured questionnaire, the WHO-5 Well-being Index (WHO-5), the Job Insecurity Index (JII), the Work Ability Index (WAI), and the Well-Being at Work Scale (WBWS). Included were 323 nurses (87.6% women, age M±SD 43.68±8.10 years). Tem- porary contract employees had worse quality of life (p = 0.009) and higher job insecurity: both in cognitive dimension (p = 0.013) and emotional dimension (p < 0.001). They also scored worse in the positive affect (p < 0.001), negative affect (p = 0.002) and fulfillment of expectations in work environment (p < 0.001) domains of the WBWS. Additionally, they reported less frequently occupational accidents and injuries (p = 0.001), muscu - loskeletal disorders of the spine or neck (p = 0.007), cardiovascular (p = 0.017), and gastrointestinal (p = 0.010) disorders, while they reported more frequently mental disorders (p < 0.001). Multivariate linear regression analysis showed that temporary work predicted high cognitive (p = 0.010) and emotional (p < 0.001) insecurity, low positive emotions and mood index (p = 0.007), low achievement-fulfillment index (p = 0.047) and high index of negative emotions (p = 0.006), regardless of gender and age. Temporary employment among nurses is associated with a lower sense of job security and well-being, and a higher prevalence of mental disorders, independently of age or gender without a significantly negative effect on their ability to work. Managers, as well as occupational physicians, should recognize the extent of nurses' job insecurity and assess their ability to work, to provide them with the necessary support and to stimulate the sense of occupational security and work capacity, so that they can thrive in their workplace and therefore be more productive and provide high quality healthcare. Int J Occup Med Environ Health. 2024;37(1):98-109.

Early evaluation of a DBT-informed online intervention for people with eating disorders.

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an onlineemotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours. We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention. We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours. Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

Trends in Health Service Use for Dry Eye Disease From 2017 to 2021: A Real-World Analysis of 369,755 Outpatient Visits.

We aimed to analyze the trends and patterns in outpatient health service treatment of dry eye disease (DED) using real-world data from Yinzhou District in China. The Yinzhou Health Information System is a comprehensive database including electronic medical records from 277 medical institutions representing over 1.64million residents. We extracted outpatient records from January 1, 2017, to December 31, 2021, that included the first diagnosis of DED according to the International Classification of Diseases, 10th Revision (H04.101, H04.103, H11.104, H16.202, or H18.803). We analyzed the trends and patterns of DED outpatient visits using the Mann-Kendall trend test and Cochran-Armitage trend test. We identified a total of 369,755 outpatient visits from 145,712 patients with DED of all ages (60.37% female; 54.10% 50years or older). Primary medical institutions had the largest number of DED outpatient visits (42%), followed by tertiary medical institutions (35%). Over the 5-year period, the number of DED outpatient visits increased from 59,260 to 90,807 (53.23%). We observed significant consecutive annual proportion increases in females (from 61.09% to 62.01%; P = 0.001), patients 50years or older (from 55.10% to 60.08%; P < 0.001), and outpatient visits in primary medical institutions (from 33.19% to 48.75%; P < 0.001). Our study found an increase in outpatient health service use for DED in Yinzhou from 2017 to 2021, with higher proportions and increases among females, patients 50years or older, and primary medical institutions. The rapid growth in the prevalence of DED indicates high eye healthcare needs in patients.

Evaluating the influence of primary healthcare nurse practitioners' interventions in home care on hospitalizations and emergency department transfers.

Home care allows patients with functional limitations to receive services at home and prevent health decline. Home care can reduce hospitalization and emergency department (ED) transfers. Integrating primary healthcare nurse practitioners (PHCNPs) in home care increases the supply of services, but little is known about their influence on patients' ability to remain at home. Evaluate the influence of PHCNPs' interventions on hospitalizations and ED transfers in patients receiving care from interprofessional home care teams with PHCNPs. The retrospective cohort study employed multiple logistic regression and Cox modelling techniques to assess the influence of PHCNP interventions on hospitalizations and ED transfers. Descriptive and bivariate analyses examined sample characteristics and variable associations. Four purposively selected sites in Québec, Canada, were included. Data were collected from electronic health records of all patients (n = 343) receiving home care from these teams. The characteristics of the sites, sample, and PHCNP interventions were described. Planned interventions led to a 5.8% decrease in hospitalizations and ED transfers (adjusted odds ratio [OR]: 0.058, p = 0.039), while unplanned interventions resulted in a 1.5-fold increase in this outcome (adjusted OR: 1.518, p < 0.001). The risk of hospitalization and ED transfers increased by 10.7 times with unplanned interventions (adjusted OR: 10.651, p = 0.002). Furthermore, imaging was associated with a 2-fold increased risk (adjusted OR: 1.954, p = 0.021), consultations with a 1.8-fold increased risk (adjusted OR: 1.849, p = 0.034), and laboratory test-related interventions after 30 or more days reduced the risk by 68.0% (adjusted OR: 0.320, p < 0.001). PHCNPs in interprofessional home care teams show promise in reducing hospitalizations and ED transfers through planned visits. These findings provide valuable insights that can contribute to enhancing home care services for a population with limited access to healthcare and high healthcare needs. Further research is needed in other jurisdictions.

Fracture-related infection in revision proximal femoral intramedullary nails

BackgroundThe proximal femoral nail is a commonly used fixation device for extra-capsular neck of femur fractures at our UK NHS Trust. Fracture-related infection (FRI) is a catastrophic complication that can be associated with internal fixation. FRI is often diagnosed late, and causes significant impact on the patient and healthcare system, leading to extended hospital stays, reduced quality of life, high healthcare costs and increased mortality and morbidity. AimThis study aims to evaluate whether failed proximal femoral nails treated at a major trauma centre in the United Kingdom are undergoing routine intraoperative microbiology sampling, as outlined by the FRI Consensus Group in 2020, and also to establish how often fracture-related infection is present in failed proximal femoral nails. MethodElectronic patient record systems were reviewed over a 4-year period between 2018–2022 to identify patients who had a proximal femoral nailing, and those who required revision surgery. From this cohort, we then identified whether sampling had taken place during revision surgery, and the number of samples taken. Results1041 proximal femoral nails were performed at our trust during the 4-year period. 60 of these implants failed, with 52 of these undergoing revision surgery at our hospital. Only 56% cases had intra-operative samples taken for microbiology testing, with an average of 9 samples sent per case. Intra-operative sampling confirmed infection in 25% of cases with samples sent. Of the cases requiring ≥ 3 operations, 75% of cases had confirmed infection. DiscussionThe data shows that more can be done to ensure earlier diagnosis of fracture-related infection in failed proximal femoral nails. We should have a high suspicion of FRI in this cohort of patients. This study highlights the importance of a standardised protocol to ensure routine intra-operative sampling during proximal femoral nail revision surgery.

Care Models and Discharge Services for Children With Medical Complexity.

Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation. We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use. Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists. Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes.

Engineering Innervated Musculoskeletal Tissues for Regenerative Orthopedics and Disease Modeling.

Musculoskeletal (MSK) disorders significantly burden patients and society, resulting in high healthcare costs and productivity loss. These disorders are the leading cause of physical disability, and their prevalence is expected to increase as sedentary lifestyles become common and the global population of the elderly increases. Proper innervation is critical to maintaining MSK function, and nerve damage or dysfunction underlies various MSK disorders, underscoring the potential of restoring nerve function in MSK disorder treatment. However, most MSK tissue engineering strategies have overlooked the significance of innervation. This review first expounds upon innervation in the MSK system and its importance in maintaining MSK homeostasis and functions. This will be followed by strategies for engineering MSK tissues that induce post-implantation in situ innervation or are pre-innervated. Subsequently, research progress in modeling MSK disorders using innervated MSK organoids and organs-on-chips (OoCs) is analyzed. Finally, the future development of engineering innervated MSK tissues to treat MSK disorders and recapitulate disease mechanisms is discussed. This review provides valuable insights into the underlying principles, engineering methods, and applications of innervated MSK tissues, paving the way for the development of targeted, efficacious therapies for various MSK conditions.

In-patient evolution of a high-persister Escherichia coli strain with reduced in vivo antibiotic susceptibility.

Gram-negative bacterial bloodstream infections (GNB-BSI) are common and frequently lethal. Despite appropriate antibiotic treatment, relapse of GNB-BSI with the same bacterial strain is common and associated with poor clinical outcomes and high healthcare costs. The role of persister cells, which are sub-populations of bacteria that survive for prolonged periods in the presence of bactericidal antibiotics, in relapse of GNB-BSI is unclear. Using a cohort of patients with relapsed GNB-BSI, we aimed to determine how the pathogen evolves within the patient between the initial and subsequent episodes of GNB-BSI and how these changes impact persistence. Using Escherichia coli clinical bloodstream isolate pairs (initial and relapse isolates) from patients with relapsed GNB-BSI, we found that 4/11 (36%) of the relapse isolates displayed a significant increase in persisters cells relative to the initial bloodstream infection isolate. In the relapsed E. coli strain with the greatest increase in persisters (100-fold relative to initial isolate), we determined that the increase was due to a loss-of-function mutation in the ptsI gene encoding Enzyme I of the phosphoenolpyruvate phosphotransferase system. The ptsI mutant was equally virulent in a murine bacteremia infection model but exhibited 10-fold increased survival to antibiotic treatment. This work addresses the controversy regarding the clinical relevance of persister formation by providing compelling data that not only do high-persister mutations arise during bloodstream infection in humans but also that these mutants display increased survival to antibiotic challenge in vivo.

Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management.

Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.

Shifting from Ammonium to Phosphonium Salts: A Promising Strategy to Develop Next-Generation Weapons against Biofilms.

Since they are difficult and sometimes impossible to treat, infections sustained by multidrug-resistant (MDR) pathogens, emerging especially in nosocomial environments, are an increasing global public health concern, translating into high mortality and healthcare costs. In addition to having acquired intrinsic abilities to resist available antibiotic treatments, MDR bacteria can transmit genetic material encoding for resistance to non-mutated bacteria, thus strongly decreasing the number of available effective antibiotics. Moreover, several pathogens develop resistance by forming biofilms (BFs), a safe and antibiotic-resistant home for microorganisms. BFs are made of well-organized bacterial communities, encased and protected in a self-produced extracellular polymeric matrix, which impedes antibiotics' ability to reach bacteria, thus causing them to lose efficacy. By adhering to living or abiotic surfaces in healthcare settings, especially in intensive care units where immunocompromised older patients with several comorbidities are hospitalized BFs cause the onset of difficult-to-eradicate infections. In this context, recent studies have demonstrated that quaternary ammonium compounds (QACs), acting as membrane disruptors and initially with a low tendency to develop resistance, have demonstrated anti-BF potentialities. However, a paucity of innovation in this space has driven the emergence of QAC resistance. More recently, quaternary phosphonium salts (QPSs), including tri-phenyl alkyl phosphonium derivatives, achievable by easy one-step reactions and well known as intermediates of the Wittig reaction, have shown promising anti-BF effects in vitro. Here, after an overview of pathogen resistance, BFs, and QACs, we have reviewed the QPSs developed and assayed to this end, so far. Finally, the synthetic strategies used to prepare QPSs have also been provided and discussed to spur the synthesis of novel compounds of this class. We think that the extension of the knowledge about these materials by this review could be a successful approach to finding effective weapons for treating chronic infections and device-associated diseases sustained by BF-producing MDR bacteria.

Comparison of Acute Health Care Utilization Between Patients Receiving In-Center Hemodialysis and the General Population: A Population-Based Matched Cohort Study From Ontario, Canada.

Patients receiving maintenance hemodialysis have multiple comorbidities and are at high risk of presenting to the hospital. However, the incidence and cost of acute health care utilization in the in-center hemodialysis population and how this compares with other populations is poorly understood. To determine the rate, pattern, and cost of emergency department visits and hospitalizations in patients receiving in-center hemodialysis compared with a matched general population. Population-based matched cohort study. We used linked administrative health care databases from Ontario, Canada. We included 25 379 patients (incident and prevalent) receiving in-center hemodialysis between January 1, 2010, and December 31, 2018. Patients were matched on birth date (±2 years), sex, and cohort entry date using a 1:4 ratio to 101 516 individuals from the general population. Our primary outcomes were emergency department visits (allowing for multiple visits per individual) and hospital admissions from the emergency department. We also assessed all-cause hospitalizations, all-cause readmissions within 30 days of discharge from the original hospitalization, length of stay for hospital admissions (including multiple visits per individual), and the financial cost of these admissions. We presented the rate, percentage, median (25th, 75th percentiles), and incidence rate per 1000 person-years for emergency department visits and hospitalizations. Individual-level health care costs for emergency department visits and all-cause hospitalization were estimated using resource intensity weights multiplied by the cost per weighted case. Patients receiving in-center hemodialysis had substantially more comorbidities (eg, diabetes) than the matched general population. Eighty percent (n = 20 309) of patients receiving in-center hemodialysis had at least 1 emergency department visit compared with 56% (n = 56 452) of individuals in the matched general population, over a median follow-up of 1.8 years (25th, 75th percentiles: 0.7, 3.6) and 5.2 (2.5, 8.4) years, respectively. The incidence rate of emergency department visits, allowing for multiple visits per individual, was 2274 per 1000 person-years (95% confidence interval [CI]: 2263, 2286) for patients receiving in-center hemodialysis, which was almost 5 times as high as the matched general population (471 per 1000 person-years; 95% CI: 469, 473). The rate of hospital admissions from the emergency department and the rate of all-cause hospital admissions in the in-center hemodialysis population was more than 7 times as high as the matched general population (hospital admissions from the emergency department: 786 vs 101 per 1000 person-years; all-cause hospital admissions: 1056 vs 139 per 1000 person-years). The median number of all-cause hospitalization days per patient year was 4.0 (0, 16.5) in the in-center hemodialysis population compared with 0 (0, 0.5) in the matched general population. The cost per patient-year for emergency department visits in the in-center hemodialysis population was approximately 5.5 times as high as the matched general population while the cost of hospitalizations in the in-center hemodialysis population was approximately 11 times as high as the matched general population (emergency department visits: CAN$ 1153 vs CAN$ 209; hospitalizations: CAN$ 21 151 vs CAN$ 1873 [all costs in 2023 CAN$]). External generalizability and we could not determine whether emergency department visits and hospitalizations were preventable. Patients receiving in-center hemodialysis have high acute health care utilization. These results improve our understanding of the burden of disease and the associated costs in the in-center hemodialysis population, highlight the need to improve acute outcomes, and can aid health care capacity planning. Additional research is needed to address the risk of hospitalization after controlling for patient comorbidities. This is not applicable as this is a population-based matched cohort study and not a clinical trial.

Real-World Effectiveness of Biologics in Patients With Severe Asthma: Analysis of the KoSAR.

Severe asthma is associated with high morbidity and healthcare utilization; however, treatment options for these patients are limited. This study aimed to determine the therapeutic effects of biologics in clinical practice. This multicenter, retrospective cohort study included 136 patients who received biologics for at least 4 months between September 2017 and July 2022 at 25 medical centers affiliated with the Korean Severe Asthma Registry (KoSAR). The study evaluated the treatment effects, including acute exacerbation rates, maintenance of oral corticosteroid dosages, lung function, quality of life, blood eosinophil count, and fractional exhaled nitric oxide (FeNO) levels, by comparing measurements before and after 4 months of biologic treatment. Responses for each medication was evaluated based on the Global Evaluation of Treatment Effectiveness score, and any adverse reactions were summarized. With the administration of biologics over the course of 4 months, there was a reduction in asthma acute exacerbations, a significant improvement in lung function, and a significant decrease in daily maintenance dose of oral steroid. Blood eosinophil counts decreased in the mepolizumab and reslizumab groups, while FeNO levels decreased only in the dupilumab group. The Asthma Control Test, Quality of Life Questionnaire for Adult Korean Asthmatics, and the EuroQol-visual analogue scale scores showed a significant improvement. Most patients (80.15%) responded to the biologic treatment. Meanwhile, non-responders often had chronic rhinosinusitis as a comorbidity, exhibited lower lung function, and required higher doses of oral steroids. No severe adverse events were reported. Biologics are highly effective in Korean patients with Type 2 severe asthma, significantly reducing acute exacerbation rates and doses of oral corticosteroids, while also improving lung function. Therefore, it seems beneficial to administer biologics without any restrictions to patients exhibiting Type 2 severe asthma.

Invasive fungal infections in critically ill children: epidemiology, risk factors and antifungal drugs.

Invasive fungal infections (IFIs) are important infectious complications amongst critically ill children. The most common fungal infections are due to Candida species. Aspergillus, Zygomycetes and Fusarium are also emerging because of the empirical use of antifungal drugs. This updated review discusses the epidemiology of IFIs as well as antifungal drugs, dosing and potential adverse effects in critically ill children. A PubMed search was conducted with Clinical Queries using the key terms "antifungal", "children", "critical care" AND "paediatric intensive care unit" OR "PICU". The search strategy included clinical trials, randomized controlled trials, meta-analyses, observational studies and reviews and was limited to the English literature in paediatrics. Candida and Aspergillus spp. are the most prevalent fungi in paediatric IFIs, causing invasive candidiasis infections (ICIs) and invasive aspergillosis infections (IAIs), respectively. These IFIs are associated with high morbidity, mortality and healthcare costs. Candida albicans is the principal Candida spp. associated with paediatric ICIs. The risks and epidemiology for IFIs vary if considering previously healthy children treated in the paediatric intensive care unit or children with leukaemia, malignancy or a severe haematological disease. The mortality rate for IAIs in children is 2.5-3.5-fold higher than for ICIs. Four major classes of antifungals for critically ill children are azoles, polyenes, antifungal antimetabolites and echinocandins. Antifungal agents are highly efficacious. For successful treatment outcomes, it is crucial to determine the optimal dosage, monitor pharmacokinetics parameters and adverse effects, and individualized therapeutic monitoring. Despite potent antifungal medications, ICIs and IAIs continue to be serious infections with high mortality rates. Pre-emptive therapy has been used for IAIs. Most guidelines recommend voriconazole as initial therapy of invasive aspergillosis in most patients, with consideration of combination therapy with voriconazole plus an echinocandin in selected patients with severe disease. The challenge is to identify critically ill patients at high risks of ICIs for targeted prophylaxis. Intravenous/per os fluconazole is first-line pre-emptive treatment for Candida spp. whereas intravenous micafungin or intravenous liposomal amphotericin B is alternative pre-emptive treatment.This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Determinants of out-of-Pocket Healthcare Expenditure by Households in Sierra Leone

The study sought to identify the determinants that influence Sierra Leonean households’ out-of-pocket healthcare expenditure. The research explicitly examined the demographic and socioeconomic determinants that impact out-of-pocket healthcare expenditure by households in Sierra Leone. The study was based on the positivism philosophy and used secondary data from the 2018 Siera Leone Household Integrated Survey to address the study objectives. Logistic regression analysis was conducted to see whether there were any relationships between the dependent and independent variables. The analysis revealed that Sierra Leone’s out-of-pocket healthcare expenditure is influenced by several demographic and socio-economic determinants which should be monitored by the policymakers. Sierra Leone households’ out-of-pocket healthcare expenditure is influenced by the household size (p &lt; 0.001), place of residence (p=0.03), employment status of the head of household (p=0.008), health provider consultation (p &lt;0.001) and wealth quintile (p&lt;0.001). The government should continue to identify and address the main causes of high OOP healthcare expenditure. A concerted effort is necessary to reduce high out-of-pocket health expenditures by improving prepaid health payment arrangements. The study provides information that governments may use to establish policies that reduce the financial burden that families endure when seeking medical care. To address structural determinants of access to healthcare, such as availability, distribution, accessibility, and quality, regardless of an individual’s location or socioeconomic status, the government could implement policies and activities aimed at increasing the availability, accessibility, and quality of healthcare services without the households suffering financial burden. The study encountered limitations inherent in the use of secondary data; however, these constraints do not undermine the validity of the findings. Such estimations remain crucial in advancing research on healthcare financing, providing valuable insights despite the methodological challenges associated with secondary data sources.

On the prediction of the effect of bi-ventricular assistance after cardiac explantation on the vascular flow physiology: A numerical study

Heart failure is a chronic and progressive condition characterized by the heart’s inability to pump sufficient blood to meet the body’s metabolic demands. It is a significant public health concern worldwide, associated with high morbidity, mortality, and healthcare costs. For advanced heart failure cases not responding to medical therapy, heart transplantation or mechanical circulatory support with ventricular assist devices (VADs) can be considered. In the specific case of bi-ventricular heart failure a replacement of both ventricles is required. In this context a Total Artificial Heart (TAH) may be proposed as a bridge to transplant solution. Additionally, bi-ventricular assist devices (BiVADs) are available to support both ventricles simultaneously. However Bi-ventricular heart failure management is difficult with poor outcomes. New surgical procedures appear to propose solutions after both ventricle failure. One of these intervention uses two continuous-flow VADs as a total artificial heart after cardiac explantation due to myocardial sarcoma. Unfortunately, this procedure makes patient management very difficult as pulmonary pressures and flow rate are no longer measurable after the surgical procedure. The setting of both pumps is hence a complex task for patient management. This article aims at helping clinicians on patient management undergoing double assistance after cardiac explantation by predicting the different outcomes on the vascular grid for all the possible rotational speed combination using a lumped model. Results provide a range of both pump operating conditions suitable for delivering a physiologically adapted flow to the vascular grid when combined with hypotensive treatments.