Specialist Intervention Research Articles

The effect of asthma specialist intervention on asthma control among adults

BackgroundVarious ways to improve asthma control have been studied, with only a modest effect. PurposeTo evaluate the effect of asthma specialist visit on asthma control among adult asthma patients. Patients and methodsThis matched cohort study included patients ages 21–50 with asthma and at least 1 visit to an asthma specialist. Patients were compared to adult asthma patients treated only by primary care physicians. The study outcomes, included use of asthma medication, healthcare visits, and mortality. All outcomes were compared one year before and after specialist visit. Results4166 pairs were included in the study. In the study group, a statistically significant decrease in the average number of relievers (1.5 ± 3.2 vs. 1.17 ± 2.9, p < 0.001) and systemic steroids purchased (0.53 ± 1.2 vs. 0.4 ± 1.2, p < 0.001), with an increase in average number of inhaled steroid purchased (1.6 ± 2.5 vs. 2.3 ± 33, p < 0.001) was seen over time. A significant decrease in the average number of PCP visits (9.5 ± 7.2 vs. 8.9 ± 7.3, p < 0.001), emergency department (ED) visits (0.46 ± 1 vs. 0.4 ± 0.9, p = 0.05) and all-cause hospitalization (0.03 ± 0.22 vs. 0.01 ± 1.9, p < 0.001) was seen in the study group but not in controls. Generalized linear modeling demonstrated an overall significant effect of specialist intervention for all parameters (p < 0.01), except ED visits (p = 0.06). During follow-up, eight (0.2%) study group patients vs. 19 (0.5%) controls died (p = 0.03). ConclusionWe found that asthma specialist intervention significantly improved asthma outcomes in adults. Referring adult asthma patients to an asthma specialist should be a goal of asthma management plans. Trial registrationNot relevant.

GAPS IN CLINICAL CARE ESCALATION AMONG SEVERE, PERSISTENT ASTHMA PATIENTS FOLLOWING INDICATORS OF UNCONTROLLED ASTHMA

<h3>Introduction</h3> Approximately 5-10% of patients with asthma have severe asthma (SA). Standard of care recommends escalation of care with uncontrolled disease. To evaluate current gaps in care in the US, this analysis examined care received among SA patients following events indicating uncontrolled disease (EUD). <h3>Methods</h3> Administrative claims databases for SA patients with Medicare Fee-for-Service, Medicare Advantage, Managed Medicaid, or commercial insurance spanning 2015-2020 were utilized. Severe, persistent asthma patients were indexed hierarchically on asthma-related EUD: ≥1 hospitalization, ≥2 emergency department (ED) visits with systemic corticosteroid treatment (SCS), 1 ED + ≥1 outpatient (OP) visit with SCS, or ≥2 OP visits with SCS. SA patients without any events were matched as controls. All were required to be 12+ years old, have 12 months enrollment pre- and post-index, and have no other major respiratory disease or biologic treatment during the pre-period. Specialist visits and medication escalation were examined during the post-index period. <h3>Results</h3> 181,548 SA patients were identified (90,774 uncontrolled, 90,774 controlled). Across payer channels, 33-51% of uncontrolled SA patients presented no specialist nor medication escalation intervention (Figure). Patients with 2 ED visits were most likely to present an absence of any intervention. <h3>Conclusion</h3> Results demonstrate that a substantial portion of uncontrolled SA patients do not have evidence of care escalation following uncontrolled disease, highlighting substantial gaps in care. Guidelines in the US recommend referral to an asthma specialist for systematic assessment or co-management for all SA patients, particularly those with uncontrolled disease. Accelerating subspecialist referrals and/or medication escalation may improve asthma care.

Recognising eating disorders in older people.

Changes in eating behaviours, weight and mental health in older people may be related to psychological distress and indicate the presence of a diagnosable eating disorder, rather than 'anorexia of ageing'. Eating disorders in older people may be overlooked because signs and symptoms are assumed to be part of normal ageing. The role of nurses in the care of older people with eating disorders is likely to be detection, referral and support in accessing specialist intervention. This article offers an overview of eating disorders in older people and discusses why they may arise, why they may not be detected and how to recognise them. The authors describe a framework that nurses can use when assessing older people to determine whether they may have an eating disorder.

85 QUALITY IMPROVEMENT INITIATIVE TO ASSESS FRAILTY AWARENESS AND USE CLINICAL FRAILTY SCALE AMONGST STAFF IN ACUTE AND PRIMARY CARE SITES

Abstract Background Frailty describes a condition characterized by decreased physiological reserve and a decreased resistance to stressors, leading to an increased vulnerability to adverse outcomes. Identification of frailty can generate greater complexity in treatment choices, care planning, and costs of care. Methods 30 inpatient, Emergency Department and Ambulatory Hub charts were audited to assess the presence of the word Frailty. The use of the Clinical Frailty Scale or alternative frailty scale was also audited. A staff survey was completed across four sites, a total of 115 staff were surveyed. Results Awareness of frailty across all services is very good ranging from 92% to 100%. The use and awareness of the Clinical Frailty Scale varied with 41% Emergency department and 12% of acute staff respectively but only 25% Emergency Department and 12% of acute staff feeling competent to complete the scale. Conversely, there was a 73% awareness of the Clinical Frailty Scale amongst primary care staff, 33% feeling competent in it's use. The Ambulatory Hub had 100% awareness of the scale with 54% of staff feeling competent. The chart audit showed that 20% of charts in the Emergency Department identified frailty, all by the Frailty Intervention Team. 26% of the inpatient charts identified Frailty by the Frailty Intervention Team's notes and from one visiting consultant. Frailty was identified and measured using the Clinical Frailty Scale in all cases of the Ambulatory Hub notes. Conclusion By identifying frailty at the first point of contact, targeted specialist interventions and services can be planned for the service user. Frailty identification on the acute site was mainly linked to the Frailty Intervention Team with the Ambulatory Hub leading out on frailty identification and measurement in the community. Future initiatives aim to increase frailty identification and awareness in acute and primary care sites.

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Abstract Background Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. Methods All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons. Results Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age &amp;gt;75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465). Conclusion There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

S1348 Patterns of GI Specialty Referral for Primary Care Patients With Nonalcoholic Fatty Liver Disease

Introduction: Early specialist intervention for patients with significant fibrosis from nonalcoholic fatty liver disease (NAFLD) is important in preventing related morbidity and mortality. For patients with evidence of hepatic steatosis, we aim to determine what proportion received gastroenterology (GI) referral, the reason for referral, and the severity of fibrosis between groups. Methods: This retrospective study of electronic health record data from 2012-2018 included patients with (i) radiographic reports of liver steatosis (abdominal ultrasound, CT, or MRI) and (ii) no competing, non-NAFLD chronic liver disease diagnoses. Referral to GI any time after imaging was the primary outcome. Chart review was conducted to determine if a patient was referred and the reason for the referral. Fibrosis-4 Index (FIB-4) scores were calculated and categorized by advanced fibrosis risk. Statistical analysis was performed with Student t-tests and Chi-square tests using SAS. Results: The cohort included 652 patients with a mean age of 55 (SD ± 14) years. Of included patients, 64% were female and 36% identified as Black. One in four patients received a formal diagnosis of NAFLD. FIB-4 scores were high-risk for advanced fibrosis in 12% of patients, indeterminate-risk for 31% of patients, and low-risk for 57% of patients. Overall, 46% of patients received a GI referral, with 32% of these referrals being for colonoscopy. A larger portion of referred patients (33%) received a diagnosis of NAFLD during the study period compared to those not referred (19%, p< 0.001). Of patients referred for non-colonoscopy reasons, only 15% of referral orders mentioned steatosis. When fatty liver disease was mentioned at referral, a larger proportion of patients received a formal NAFLD diagnosis compared to all other non-colonoscopy referrals (80% vs. 26%, p< 0.001). There was no difference in the proportion of high-risk FIB-4 scores between patients with and without a GI referral (p=0.95). Conclusion: Appropriate GI referral for NAFLD management remains a concern, even so NAFLD is predicted to be the leading indication for liver transplantation within the next 10 years. Our data suggests hepatic steatosis is infrequently recognized as a notable finding on abdominal imaging and did not prompt excessive GI referral. Use of FIB-4 scoring has been shown to reduce unnecessary referral and improve detection of advanced fibrosis, though FIB-4 scoring did not influence referral likelihood in this cohort.

Hoarding and the Substance of Kinship

While much has been written in popular media about the apparent antisociality of hoarders, many people with parents who exhibit hoarding tendencies describe intense (though not always positive or desirable) forms of kin relationality that grow in and around domestic hoards. Based on fieldwork with hoarding intervention specialists, interviews with people who identify as "Adult Children of Hoarders" (ACoHs), and a review of recent memoirs on the topic, this article examines how domestic hoards enable and restrict the interactions, habits, and movements of those who live within them, and in turn, how kin relations get made and troubled in relation to the hoard. I consider the hoard as kinship substance in its own right, and in doing so, reflect upon both the variable meanings of—and the analytic work performed by—the term "substance" in kinship studies over the past four decades. In showing how familial relationships come to be shaped and mediated by the hoard (hoard-as-substance), and even beyond this, how the hoard may itself come to be imagined as kin (hoard-as-kin), this article offers a counterpoint to studies that overemphasize the positive aspects and affects of kinship and relatedness.

Variation in access rates amongst patients groups in Wales for specialist interventions.

ObjectivesThe Welsh Health Specialised Services Committee (WHSSC) has commissioned a study to assess if there is a standard value-based approach to measure and evaluate the effectiveness of specific interventions, and whether variation exists that may indicate differences in the equity of access to these services provided to patients in Wales.&#x0D; ApproachUsing anonymised individual-level, population-scale, routinely collected electronic health record (EHR) data held within the Secure Anonymised Information Linkage (SAIL) Databank, we planned to identify amongst the population of Wales any patients experiencing percutaneous coronary intervention (PCI) and Transcatheter Aortic Valve Implantation (TAVI). We would measure associated patient outcomes 2-years before and after the intervention minus a 6-month clearance period on either side by measuring primary care attendances in general practice, and secondary care attendances in hospital, outpatient and emergency department data. To further inform the analysis, linkage to socio-demographic factors, comorbidities and lifestyle factors would be controlled for.&#x0D; ResultsPreliminary results identified 5,999 PCIs between June 2014 and March 2020. We were able to identify 1,530 as elective and 4,358 as emergency secondary care procedures. Of the elective PCIs, 184 patients had a greater number of elective hospital days pre-PCI, and 382 patients had a greater number of elective hospital days post-PCI. Of the emergency PCIs, 135 patients had a greater number of emergency hospital days pre-PCI, and 893 patients had a greater number of emergency hospital days post-PCI. For TAVI intervention, we identified 74 elective and 49 emergency procedures. 35 of the elective TAVI had greater hospital days pre-intervention, and 17 of the elective TAVI had greater hospital days post-intervention. Primary care costs slightly rose for PCI and slightly reduced for TAVI.&#x0D; ConclusionWe successfully identified interventions and measured and contrasted outcomes before and after the intervention using the SAIL Databank. For PCI, the elective intervention showed a reduced increase in bed days compared to emergency intervention. These initial findings allow us to plan an expanded analysis to examine other intervention types.

Qualitative Findings for Supporting Newly Graduated Nurse and Teacher Sleep During Their First Year.

New graduate role transition for nurses and teachers is stressful. Poor adaptation may manifest as insomnia, which has implications for the new professionals, their employers, and the public served. This study examines factors that impact new graduate sleep, with the aim of identifying perceived helps and hindrances to sleep-during-transition. Targeted content analysis of transcripts from a larger longitudinal mixed methods study comparing new graduate sleep during their first year of practice. Study participants (N = 21) answered questions in the final interview regarding the most positive and negative impact(s) on sleep during the transition year. Transcripts were analyzed and compared based on the new graduate sleep typology (i.e., Got Better, Got Worse, Stayed Varied) which emerged from the parent study. Most participants, regardless of sleep type, identified a person/group as most positively impacting sleep. They identified work thoughts, stress/anxiety, people, work hours/sleep schedules, and environmental factors as negatively impacting sleep. Work thoughts and stress/anxiety were mentioned together and most frequently by participants in all three sleep types. This study provided insight into new graduate nurse and teacher sleep during transition. Support persons and/or groups may be essential regardless of sleep type. Thought management/stress mitigation strategies and good sleep hygiene may also improve the sleep experiences of these new professionals. Occupational health nurses can support sleep-during-transition among new nurses and teachers by acting as sleep advocates. They may also identify a need for medical intervention and/or sleep specialists and should promote fatigue risk mitigating policies.

A Demedicalized Model to Provide PrEP in a Sexual Health Clinic.

Sexual health clinics (SHCs) serve large numbers of patients who might benefit from preexposure prophylaxis (PrEP). Integrating longitudinal PrEP care into SHCs can overburden clinics. We implemented an SHC PrEP program that task shifted most PrEP operations to nonmedical staff, disease intervention specialists (DIS). We conducted a retrospective cohort analysis of PrEP patients in an SHC in Seattle, WA, from 2014 to 2020 to assess the number of patients served and factors associated with PrEP discontinuation. Clinicians provide same-day PrEP prescriptions, whereas DIS coordinate the program, act as navigators, and provide most follow-up care. Between 2014 and 2019, 1387 patients attended an initial PrEP visit, 93% of whom were men who have sex with men. The number of patients initiating PrEP per quarter year increased from 20 to 81. The number of PrEP starts doubled when the clinic shifted from PrEP initiation at scheduled visits to initiation integrated into routine walk-in visits. The percentage of visits performed by DIS increased from 3% in 2014 to 45% in 2019. Median duration on PrEP use was 11 months. PrEP discontinuation was associated with non-Hispanic black race/ethnicity [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.02 to 1.76], age <20 years (HR 2.17, 95% CI: 1.26 to 3.75), age between 20 and 29 years (HR 1.55, 95% CI: 1.06 to 2.28), and methamphetamine use (HR 1.98, 95% CI: 1.57 to 2.49). The clinic had 750 patients on PrEP in the final quarter of 2019. A demedicalized SHC PrEP model that task shifts most operations to DIS can provide PrEP at scale to high priority populations.

Do Symptoms Correlate with the Signs in Odontogenic Sinusitis with Periapical Lesions?

Introduction: Endodontic pathology is one of the most common causes of odontogenic sinusitis, and its evaluation is challenging. Omission of periapical lesions in diagnostic process leads to recurrent sinusitis after cessation of medical therapy. Methods: Sixty-one symptomatic patients presented with odontogenic sinusitis with periapical lesions of teeth adjacent to the maxillary sinus were included in the study. Symptoms evaluated with SNOT-22 and OHIP-14 questionnaires were compared to signs during endoscopic and radiological evaluation. Results: Coexistence of odontogenic sinusitis with nasal polyps significantly decreases the quality of life, especially concerning the emotional domain (p = 0.047). Patency of ostiomeatal corresponds well with the severity of sinonasal symptoms reported with SNOT-22 (p = 0.051). Extent of maxillary sinus opacifications scored with Zinreich scale correlates positively with the presence of discharge (p = 0.001) and edema (p = 0.072) in the endoscopic Lund-Kennedy scale. Among 67 teeth with periapical lesions, 73.1% had undergone previous root canal treatment, but in 47.8% of cases, it was defined as incomplete. Endodontic status did not affect the severity of patient’s complaints. Conclusion: In case of odontogenic sinusitis of endodontic origin, endoscopic signs correlate better than radiological with the self-reported symptoms. In order to better evaluate the severity of the disease and possible need of surgical intervention, both otolaryngologists and dental specialists should focus on extent of inflammatory lesions in the maxillary sinus.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma

IntroductionTrauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia. MethodsThis retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use. Results4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9–26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2–9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care. ConclusionsNon-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

The use of lumbar puncture and safety recommendations in Alzheimer's disease: a plain language summary.

This is a plain language summary of an article published in Alzheimer's & Dementia. It looks at a type of test called a lumbar puncture (also known as spinal tap) used in people suspected of having Alzheimer's disease or some other form of dementia. This summary focuses on how to do a lumbar puncture safely. Alzheimer's disease is a progressive condition, which means it gets worse over time. This leads to difficulties with thinking and memory. People with Alzheimer's disease show a build up of proteins called amyloid-β and tau in the brain. This is followed by a gradual loss of brain cells and brain function. The changes in the brain are thought to occur years before symptoms appear. Lumbar puncture is a medical procedure during which samples of cerebrospinal fluid are collected. In Alzheimer's disease, it is used to examine cerebrospinal fluid biomarkers that can help diagnose disease. Lumbar puncture is traditionally considered as a painful and invasive procedure with frequent side effects. However, multiple studies indicate that a lumbar puncture can be performed safely. Side effects are typically mild and do not require specialist intervention. Despite the low risk of serious complications associated with a lumbar puncture, physicians and their patients may be reluctant to recommend or undergo this procedure. Patient education, specialist training, as well as new methods concerning patient safety are important factors to support the widespread use of lumbar puncture in Alzheimer's disease.

Evaluating and optimizing bone health in children with chronic health conditions.

Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.

State Policies Relevant to Disease Intervention Specialists in the United States.

The functions of disease intervention specialists (DIS) represent core infectious disease control practices and have legal foundations in the United States. Although important for state and local health departments to understand this authority, these policies have not been systematically collected and analyzed. We analyzed the authority for investigation of sexually transmitted infections (STIs) across all 50 US states and the District of Columbia. In January 2022, we collected state policies addressing the investigation of STIs using a legal research database. We coded these policies into a database on variables of interest: (1) whether the policy authorized/required investigation, (2) what type of infection triggers an investigation, (3) and the entity who is authorized/required to perform the investigation. All 50 US states and District of Columbia explicitly authorize/require investigation of cases of STI. Of these jurisdictions, 62.7% require investigations, 41% authorize investigations, and 3.9% both authorize and require investigations. Sixty-seven percent authorize/require investigations for cases of communicable disease (inclusive of an STI), 45.1% authorize/require investigations for cases of STIs generally, and 3.9% authorize/require investigations for cases of a specific STI. Eighty-two percent of jurisdictions authorize/require the state to investigate, 62.7% authorize/require local governments to investigate, and 39.2% authorize/require investigations by both state and local governments. State laws that establish authority or duties regarding the investigation of STIs differ across states. It may be useful for state and local health departments to examine these policies relative to the morbidity of their jurisdiction and their STI prevention priorities.

Evaluating 12 Years of Implementing a Multidisciplinary Specialist Child and Adolescent Obesity Treatment Service: Patient-Level Outcomes.

IntroductionChildhood obesity is a chronic disease that requires multidisciplinary and specialist intervention to address its complex pathophysiology, though access to treatment is limited globally. Evaluating the impact of evidence-based interventions implemented in real-world clinical settings is essential, in order to increase the translation of research into practice and enhance child health outcomes. In Ireland, the National Model of Care for Obesity highlighted the need to develop and improve healthcare services for children and adolescents with obesity.AimsThis study aims to evaluate the impact of a family-based, Tier 3 multi-disciplinary child and adolescent obesity outpatient service (www.w82go.ie) on standardized body mass index (BMI-SDS).MethodsFollowing referral by pediatricians, patients were assessed by a pediatric multidisciplinary team (physiotherapist, dietician, and psychologist) and personalized obesity treatment plans were developed. Anthropometric and demographic information were recorded at baseline and final visit. Descriptive statistics were used to explore distribution, central tendency and variation in the demographic data, change in BMI-SDS over time was assessed using a t-test, and multiple linear regression analysis was used to investigate the association of demographic factors on the change in BMI-SDS.ResultsThe overall mean BMI-SDS reduction across the whole cohort (n = 692) was −0.17 (95% CI = −0.20, −0.13; P < 0.001). Younger age at admission and longer duration of treatment were associated with greater BMI-SDS reduction but there was no significant association between change in BMI-SDS and any of the other parameters (deprivation score, treatment type, sex, obesity category at admission or presence of comorbid condition).ConclusionEngagement in a specialist Tier 3 pediatric obesity service was associated with reductions in BMI-SDS in children and adolescents with obesity.

A Service Evaluation of the National High Secure Deaf In-Reach Service

AimsThe National High Secure Deaf Service at Rampton Hospital provides inpatient assessment, treatment and rehabilitation for D/deaf* males living with a range of difficulties including complex responses to trauma, mental health difficulties and/or learning disabilities. In 2011, the Deaf Prison In-Reach Service was established in conjunction with Yorkshire Specialist Commissioning Group and Nottinghamshire NHS Trust aiming to provide specialist support to D/deaf prisoners. * ‘D’ = Deafness as a culture, ‘d’ = deafness as a medical disability.MethodsThe team evaluated the service to raise awareness of the specific needs of D/deaf prisoners by identifying and describing characteristics, demographics, trends and patterns within existing data as well as highlighting the nature of offences, prevalence of trauma and length of time over tariff. A secondary aim was to identify areas for development to adequately meet the needs of D/deaf prisoners.ResultsAfter reviewing data for 29 prisoners (female = 3, male = 26), the most common source of support offered by the DPRIS was signposting (over 50%), followed by direct individual work (with nursing or psychology), assessment and consultancy.Since 2011, the DPRIS has assessed 30 individuals and completed over 717 prison visits for assessments and interventions. Whilst this has been acknowledged as a small number, it has been attributed to the difficulties locating D/deaf prisoners and lack of awareness regarding the DPRIS. Currently, referrals to the DPRIS come from prison healthcare staff, but this fails to address the wider specialist needs of this population: basic communication needs, occupational needs and risk reduction work. It also excludes individuals unknown to healthcare.Direct engagement with the DPRIS included: focused risk reduction work, anger management, mental health monitoring, and 1:1 psychology work. Prior to involvement from the DPRIS, five individuals declined to engage in prison therapy. With support from the DPRIS, two were transferred to more appropriate placements, one was recommended for transfer (not transferred) and one received mental health monitoring (nursing). One continued to decline which could be attributed to potential (lack of) motivation/readiness.This evaluation supports the need for specialist interventions to ensure equitable access to recovery and rehabilitation.ConclusionWhat Next?It is hoped that the unique needs of this population will be communicated amongst professionals and steps will be made to address these as previously recommended in reports from the BDA (2016) and the Howard League.

Advancing data to care strategies for persons with HIV using an innovative reconciliation process.

UN AIDS has set ambitious 95-95-95 HIV care continuum targets for global HIV elimination by 2030. The U.S. HIV Care Continuum in 2018 showed that 65% of persons with HIV(PWH) are virally suppressed and 58% retained in care. Incomplete care-engagement not only affects individual health but drives ongoing HIV transmission. Data to Care (D2C) is a strategy using public health surveillance data to identify and re-engage out-of-care (OOC) PWH. Optimization of this strategy is needed. Statewide partnership with Connecticut Department of Public Health (CT DPH), 23 HIV clinics and Yale University School of Medicine (YSM). Our site was one of 3 participants in the CDC-sponsored RCT evaluating the efficacy of DPH-employed Disease Intervention Specialists (DIS) for re-engagement in care. From 11/2016-7/2018, a data reconciliation process using public health surveillance and clinic visit data was used to identify patients eligible for randomization (defined as in-Care for 12 months and OOC for subsequent 6-months) to receive DIS intervention. Clinic staff further reviewed this list and designated those who would not be randomized based on established criteria. 2958 patients were eligible for randomization; 655 (22.1%) were randomized. Reasons for non-randomizing included: well patient [499 (16.9%)]; recent visit [946 (32.0%)]; upcoming visit [398 (13.5%)]. Compared to non-randomized patients, those who were randomized were likely to be younger (mean age 46.1 vs. 51.6, p < .001), Black (40% vs 35%)/Hispanic (37% vs 32.8%) [(p < .001)], have CD4<200 cells/ul (15.9% vs 8.5%, p < .001) and viral load >20 copies/ml (43.8% vs. 24.1%, 0<0.001). Extrapolating these estimates to a statewide HIV care continuum suggests that only 8.3% of prevalent PWH are truly OOC. A D2C process that integrated DPH surveillance and clinic data successfully refined the selection of newly OOC PWH eligible for DIS intervention. This approach more accurately reflects real world care engagement and can help prioritize DPH resources.

Overuse of Oral Corticosteroids in Asthma Is Often Underdiagnosed and Inadequately Addressed

Overuse of oral corticosteroids (OCS) is associated with serious adverse effects. It is currently unknown what proportion of patients with asthma regularly use these drugs, or whether they are optimally treated by specialists to minimize the use of these drugs. To investigate (1) the prevalence of patients requiring ≥2 courses or maintenance use of OCS (ie, frequent users), (2) their use of inhaled corticosteroids, and (3) who prescribed their asthma medications. We analyzed OCS prescription data (Dutch IQVIA Prescription Database) focusing on adult patients receiving asthma medication between March 2017 and March 2018 (focus year). An OCS course was defined as ≥20 mg prednisolone equivalent for 3 to 28 days; maintenance OCS as 2.5 to 17.5 mg/day for >28 days. Prescribers were classified as specialist or general practitioners. Of 182,849 adults taking asthma medications, 77.8% had not received a prescription for OCS and 7.2% of patients were frequent OCS users: 2.6% received ≥2 OCS courses and 4.6% were on maintenance OCS. Of the frequent OCS users, 45.8% received only low or medium doses (<500 μg/day) of inhaled corticosteroids. Within the preceding 3 years (2014-2017), 51.1% and 34.3% of patients prescribed ≥2 OCS courses or maintenance OCS, respectively, had received prescriptions from a general practitioner without medication adjustments by a specialist. This prescription-fill study shows that 7.2% of Dutch patients with asthma were overexposed to OCS, of whom only about half used adequate doses of inhaled corticosteroids, and 40.3% had not received specialist intervention within the previous 3 years. This suggests that OCS overuse is often underdiagnosed and inadequately addressed.

Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.