Ongoing Medical Care Research Articles

Long-Term Outcomes of Acute Osteoarticular Infections in Children.

Background: Acute hematogenous osteomyelitis (OM) and septic arthritis require immediate diagnosis and treatment by an interdisciplinary team of pediatric infectious disease specialists and pediatric orthopedic surgeons. Adverse outcomes such as growth disturbance, bone deformity, and chronic infections have been described in older studies. However, there is only little known about long-term follow-up of patients of the last two decades. Therefore, we aimed to evaluate subjective and objective long-term outcomes of these children with osteoarticular infections treated in the millennial years.Methods: Cross-sectional study performed in two pediatric centers including patients admitted for OM and/or SA between 2005 and 2014 and follow-up consultations in 2019. Patients with symptoms of ≤2 weeks duration at initial presentation were contacted. Subjective outcomes were assessed by standardized interview, objective outcomes by clinical examination. Medical charts were used to extract data from the initial presentations. Statistical analysis was performed by non-parametric tests and Fisher's exact test.Results: Of 147 eligible patients 77 (52%) agreed to participate, of which 68 (88%) had an interview and physical examination and 9 (12%) an interview only. Thirty-three (39%) had OM, 26 (34%) SA, and 21 (27%) combined OM/SA. Median (IQR) age at follow-up was 13.3 (10.5–18.0) years with a median (IQR) follow-up of 7.1 (6.1–8.6) years. Persistent complaints including pain, functional differences and scar paresthesia, reported by 21 (28%) patients, were generally mild and only 3 (5%) required ongoing medical care. Objective sequelae including pain, limited range of motion, unilateral axis deformity or asymmetric gait were found in 8 (12%) participants. Older age, female sex, joint involvement, surgical intervention, persistent fever, and C-reactive protein elevation were associated with adverse clinical outcome.Conclusions: Adverse outcomes were observed in a considerable number of patients, most of which were minor, and only few required ongoing medical care. Long-term follow up is advisable for patients with risk factors identified during the initial presentation.This study was registered on ClinicalTrials.gov (NCT03827980).

What Is the Impact of the COVID-19 Pandemic on Quality of Life and Other Patient-reported Outcomes? An Analysis of the Hand-Wrist Study Cohort.

The coronavirus disease 2019 (COVID-19) pandemic, and its associated lockdowns in many parts of the world, have changed our daily lives and may have a psychological impact on around the globe. However, it is unknown how this influences the patient-reported outcome measures (PROMs) of patients involved in ongoing clinical research and medical care. For both the current and potential future lockdowns, it is important to determine if PROMs collected during such a period can be interpreted with confidence. (1) Is there a difference in quality of life between patients in the COVID-19 period group (March 23, 2020 to May 4, 2020) and patients in a reference period group (from the same period in 2018 or 2019)? (2) Is there a difference in pain, hand function, anxiety, depression, and illness perception between patients in the COVID-19 period group and patients in the reference period group? This study was part of a large cohort study with routine outcome measures of patients with hand and wrist conditions. To answer our research questions, we analyzed two samples because not all PROMs were sent to participants at the same time points after treatment. The first sample consisted of all participants who completed PROMs on quality of life (QoL), pain, and hand function at their final follow-up time point, which was either 3, 6, or 12 months post-treatment. The second sample consisted of participants who completed PROMs 3 months post-treatment on anxiety, depression, and illness perception. Each sample consisted of two groups: a COVID-19 period group and a reference period group. We included 1613 participants in the first sample (COVID-19 period group: n = 616; reference period group: n = 997) and 535 participants in the second sample (COVID-19 period group: n = 313; reference period group: n = 222). The primary outcome was QoL, expressed in the EuroQol 5-Dimensions questionnaire (EQ-5D) index score. Secondary outcomes were the other domains on the EQ-5D, as well as pain, hand function, anxiety, depression, and illness perception. We found no between-group differences in the EQ-5D index score (standardized mean difference 0.035; p = 0.98). Furthermore, there were no between-group differences in PROM scores for hand function, anxiety, or depression. There were, however, a few small differences in subdomain items regarding pain and illness perception, but we believe in aggregate that these are unlikely to make a clinically important difference in our main finding. The COVID-19 pandemic and its associated lockdown had no influence on QoL and had little influence on secondary outcomes in participants who were part of the Hand-Wrist Study Cohort. This finding implies that PROMs data collected during this period can be used with confidence in clinical research. Our findings indicate that when a pandemic like this occurs again, we can continue to use PROMs for analysis in clinical research or routine outcome measures. Level III, therapeutic study.

SARS-CoV-2 infection in liver transplant recipients: collaboration in the time of COVID-19

SARS-CoV-2 infection in liver transplant recipients: collaboration in the time of COVID-19

Health Care After the COVID-19 Pandemic and the Influence of Telemedicine

Health Care After the COVID-19 Pandemic and the Influence of Telemedicine

The COVID-19 pandemic: new concerns and connections between eHealth and digital inequalities

Purpose Telemedicine has been advancing for decades and is more indispensable than ever in this unprecedented time of the COVID-19 pandemic. As shown, eHealth appears to be effective for routine management of chronic conditions that require extensive and repeated interactions with healthcare professionals, as well as the monitoring of symptoms and diagnostics. Yet much needs to be done to alleviate digital inequalities that stand in the way of making the benefits of eHealth accessible to all. The purpose of this paper is to explore the recent shift in healthcare delivery in response to the COVID-19 pandemic towards telemedicine in healthcare delivery and show how this rapid shift is leaving behind those without digital resources and exacerbating inequalities along many axes. Design/methodology/approach Because the digitally disadvantaged are less likely to use eHealth services, they bear greater risks during the pandemic to meet ongoing medical care needs. This holds true for both medical conditions necessitating lifelong care and conditions of particular urgency such as pregnancy. For this reason, the authors examine two case studies that exemplify the implications of differential access to eHealth: the case of chronic care diseases such as diabetes requiring ongoing care and the case of time-sensitive health conditions such as pregnancy that may be compromised by gaps in continuous care. Findings Not only are the digitally disadvantaged more likely to belong to populations experiencing greater risk – including age and economic class – but they are less likely to use eHealth services and thereby bear greater risks during the pandemic to meet ongoing medical care needs during the pandemic. Social implications At the time of writing, almost 20% of Americans have been unable to obtain medical prescriptions or needed medical care unrelated to the virus. In light of the potential of telemedicine, this does not need to be the case. These social inequalities take on particular significance in light of the COVID-19 pandemic. Originality/value In light of the COVID-19 virus, ongoing medical care requires exposure to risks that can be successfully managed by digital communications and eHealth advances. However, the benefits of eHealth are far less likely to accrue to the digitally disadvantaged.

COVID-19 & Multiple Myeloma

COVID-19 & Multiple Myeloma

The Experience of a Neurocritical Care Admission and Discharge for Patients and Their Families: A Qualitative Analysis.

A qualitative assessment of discharge resource needs is important for developing evidence-based care improvements in neurocritically ill patients. We conducted a quality improvement initiative at an academic hospital and included all patients admitted to the neuroscience intensive care unit (ICU) during an 18-month period. Telephone assessments were made at 3 to 6 months after admission. Patients or caregivers were asked whether they had adequate resources upon discharge and whether they had any unanswered questions. The content of responses was reviewed by a neurointensivist and a neurocritical care nurse practitioner. A structured codebook was developed, organized into themes, and applied to the responses. Sixty-one patients or caregivers responded regarding access to resources at discharge with 114 individual codable responses. Responses centered around 5 themes with 23 unique codes: satisfied, needs improvement, dissatisfied, poor post-ICU care, and poor health. The most frequently coded responses were that caregivers believed their loved one had experienced an unclear discharge (n = 11) or premature discharge (n = 12). Two hundred four patients or caregivers responded regarding unanswered questions or additional comments at follow-up, with 516 codable responses. These centered around 6 themes with 26 unique codes: positive experience, negative experience, neutral experience, medical questions, ongoing medical care or concern, or remembrance of time spent in the ICU. The most frequent response was that caregivers or patients stated that they received good care (n = 115). Multiple concerns were brought up, including lack of follow-up after hospitalization (n = 15) and dissatisfaction with post-ICU care (n = 15). Obtaining qualitative responses after discharge provided insight into the transition from critical care. This could form the basis for an intervention to provide a smoother transition from the ICU to the outpatient setting.

Bringing Statistics to Life: Developing “Lived-Experience” Family Videos for a Periviable Decision-Support Tool [06K

INTRODUCTION: To develop and incorporate ‘lived-experience’ videos of families describing their lives following periviable delivery into the Periviable GOALS (Getting Optimal Alignment around Life Support) decision-support tool. METHODS: Through patient-engaged research methodology, patient-partners advocated ‘bringing statistics to life’ by including videos into the tool (IRB-approved). Five videos were created; each contained two families’ stories reflecting: death following comfort care, non-survival following resuscitation, or survival with mild, moderate, or severe neurodevelopmental impairment (NDI). Diverse families represented the spectrum of NDI, using different scripts for bereavement versus survival. Professional videographers filmed and edited the segments (3-5 minutes), which were embedded into the GOALS tool. Focus groups were conducted with pregnant women (20-26 weeks) and women who have delivered periviably to assess the videos’ acceptability. RESULTS: Ten families participated in the ‘lived-experience’ videos. Half were African American and half were white; children were age 16 months to 4 years. Bereaved parents were asked about end-of-life experiences and support after loss, while survivor segments described typical days, on-going medical care, and family adjustment. The videos were rated “excellent” (41.7%) or “good” (25%) by focus group participants (n=12). Most (91.7%) thought the tool provided sufficient information and would be useful in helping families make treatment decisions. CONCLUSION: Videos provide context for families to make meaning of complex prognostic information on long-term outcomes. They must be developed with caution due to their potential to introduce anchoring, conformity, or optimistic biases. Stakeholder engagement and diverse representation across the spectrum of outcomes and decisions may help to mitigate potential biases.

FREQUENCY OF PRETERM BIRTHS AMONG PREGNANT WOMEN WITH TWIN PREGNANCY AT A TERTIARY CARE HOSPITAL.

Background; Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources which translate into insufficient care during pregnancy and delivery. Due to inherent biological factors, twin pregnancies have increased rates of obstetric and perinatal complications such as preeclampsia, post-partum haemorrhage and preterm birth, which are known risk factors for maternal and perinatal mortality. Objective; To determine the frequency of preterm birth in twin pregnancies at a tertiary care hospital. Material and methods: A total of 181 patients with dichorionic diamniotic twin pregnancy on ultrasound having gestational age more than 24 weeks were taken in this cross-sectional study. Demographic information of patients (name, age, weight) was taken. Informed consent was taken from each patient, ensuring confidentiality and fact that there is no risk involved to the patient while taking part in this study. An obstetrical ultrasonography was done to confirm twin pregnancy. Blood samples were taken from all patients for assessment of anemia. Patients were followed up till delivery to determine preterm labor. Results; Mean age of these study cases was noted to be 34.35 ± 2.41 years. Mean gestational age of our study cases was 34.67 ± 2.25 weeks. Mean BMI of our study cases was noted to be 22.45 ± 1.67 kg/m 2 (with minimum BMI was 19.4 kg/m 2 and maximum BMI was 32 kg/m 2 ) and obesity was present in 27 (14.9 %) of our study cases. Of these 181 study cases, 126 (69.6%) delivered vaginally while 55 (30.4%) had to undergo cesarean section delivery. Mean hemoglobin level was noted to 8.67 ± 1.40 g/dl while anemia was seen in 126 (69.6%) of these study cases. Abruptio placentae in 19 (10.5%) and low birth weight in 123 (68 %) of our study cases. Frequency of preterm births was observed in 144 (79.6%). Conclusion; Twin pregnancy is associated with high risk of perinatal and pregnancy outcomes as very high frequency of preterm births was noted in our study. There was also higher frequency of anemia, cesarean section deliveries and low birth weight babies in our study. There is a need for specialised prenatal care to reduce complications and adverse outcome in multiple pregnancies, and the need for ongoing social and medical care beyond the prenatal and perinatal periods to improve perinatal outcomes in these patients. Keywords; Preterm labor, anemia, twin pregnancy. DOI : 10.7176/JMPB/62-11 Publication date: December 31 st 2019

Post-diagnostic management and follow-up care for autism spectrum disorder.

Paediatricians and other primary care providers are well positioned to provide or coordinate ongoing medical and psychosocial care and support services for children with autism spectrum disorder (ASD). This statement provides recommendations and information on a range of interventions and resources, to help paediatric care providers optimize care for children with ASD and support their families. The management of ASD includes treating medical and psychiatric co-morbidities, behavioural and developmental interventions, and providing supportive social care services to enhance quality of life for affected children and families.

RADIATION DOSE TRENDS AND CANCER RISK ACCRUED FROM RADIATION EXPOSURE IN THE MEDICAL ICU: A 5-YEAR PERSPECTIVE

SESSION TITLE: Tuesday Electronic Posters 2 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Patients admitted to Medical Intensive care unit (MICU) are subjected to multiple radiological studies.Some endure radiation dose exposure [Cumulative Effective dose (CED) ] in excess of annual federal occupational health standard limits (CED≥50 mSv) and those statistically linked with cancer induction (CED≥100 mSv). We evaluated the cancer risk( life time attributable risk) from the CED accrued during a single admission and radiation dose trends over a 5 year period METHODS: This is a retrospective observational study conducted in an academic medical center involving all adult admissions (N=21,108) admitted to the MICU between January 2013 and December 2017. Clinical and radiologic data were obtained from the electronic medical records and the picture archiving & communication system. Radiation doses from ionizing radiological studies were calculated from reference values to determine CED. RESULTS: Four percent of the patients (n=562) accrued CED ≥50%, 1 % (n=195) accrued CED ≥100 mSv. The median CED was 0.72 mSv (IQR, 0.02-4.08 mSv)over a five year period with a range of 0.00 mSv to 1607 mSv . The mean MICU length of stay(LOS ) was 4.7(+/-6.7 )days and APACHE score was 65.8(+/-29.6) over a 5 year period . Higher APACHE 3 scores (p< 0.001), hepatic failure (p=0.03 ), and gastrointestinal disorders (0.0001) predicted higher CED in a multivariable linear regression model. Odds ratio of accruing CED≥ 50mSv was noted at 8.9 (CI 6.84-11.59, P< 0.0001) in gastrointestinal bleeding, 2.6 (CI 2.17-4.04, p < 0.0001) in gastrointestinal disorders ,3.58 (CI 2.69-4.78 P<0.001) in hematological disorders and 1.38 (CI 0.99-1.92 p<0.001) in Cirrhosis. CT scan and interventional radiology accounted for 59% and 29% of the total CED, respectively. The median increase in cancer risk from CED accrued was 0.36(IQR, 0.23-0.58).The Median CED remained constant across 5 years without an uptrend. CONCLUSIONS: MICU patients are exposed to radiation doses that can be substantial, exceeding federal annual occupational limits and in a select subset, exceeds >100 mSv resulting in an increased cancer risk from baseline among ICU survivors. Median CED remained constant across the study period without an uptrend. Efforts to justify, restrict & optimize the use of radiological resources when feasible, are warranted. CLINICAL IMPLICATIONS: Younger MICU survivors could be at substantial cancer risk from CED accrued in the MICU within a relatively short span of time. Those discharged could be subjected to even more medical radiation as a part of ongoing medical care, adding to the annual CED and increasing the radiogenic risk further. Attempts to mitigate radiation burden by optimizing the utilization of fluoroscopically guided interventional procedures and computerized tomography merits further discussion and research. DISCLOSURES: No relevant relationships by Sinan Abdul-Wahab, source=Web Response No relevant relationships by Anirban Bhattacharyya, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Sravanthi Ennala, source=Web Response No relevant relationships by Nagamani Guduguntla, source=Web Response no disclosure on file for Jorge Guzman; No relevant relationships by Xiaozhen Han, source=Web Response No relevant relationships by Tarik Hanane, source=Web Response no disclosure on file for Ali Khwaja; No relevant relationships by Sudhir Krishnan, source=Web Response Advisory Committee Member relationship with Boston Scientific Corp. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee Consultant relationship with Terumo Interventional Corp. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee Advisory Committee Member relationship with BTG Inc. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee No relevant relationships by Xiaofeng Wang, source=Web Response

111 Adding Nuance to the Rockwood Clinical Frailty Scale

Abstract Background The Rockwood Clinical Frailty Score (CFS) is a well validated tool for assessing frailty. However, there is a paucity of data in the literature demonstrating how severity of clinical frailty correlates with adverse outcomes. This gap in the literature limits the ability of physicians, who predominantly use measures of frailty in day-to-day practice such as CFS, to fully construe the implications of increasing frailty for patients in their care. Methods In this prospective cohort study, patients (n=186) aged &gt;65 years admitted for unscheduled medical care to a district general hospital, were assigned a clinical frailty score within 24 hours of admission. Patients were then followed up for 12 months and assessed in terms of mortality, discharge to institutional care, length of hospital admission, polypharmacy and re-admission rate. Results This study found significant differences between frail and non-frail populations in terms of adverse patient outcomes including mortality, length of hospital admission, polypharmacy, co-morbidity and re-admission rates. Of greater importance still, this study found that increasing risk of adverse outcomes correlated with increasing CFS. For CFS ≤4, 5, 6, 7, 8, 9 12-month mortality rates were 7.55%, 28.6%, 31.4%, 37.14%, 87.5% and 100% respectively. For CFS ≤4, 5, 6, 7, 8, 9 rates of discharge to institutional care were 1.88%, 6.12%, 34.3%, 41.66%, 50% and 40% respectively. Conclusion These results are important as they begin to help physicians form a more nuanced interpretation of CFS. With growing emphasis on individualising patient care, binary categorisation of patients into ‘frail’ and ‘non-frail’ groups is felt to be an increasingly inadequate way of viewing frailty. This study adds information to the discourse which helps both physicians and patients to make more informed decisions regarding their on-going medical care. Larger prospective cohort studies will now be required to understand correlation between severity of frailty and patient outcomes.

ASSOCIATION OF ADVERSE PERINATAL OUTCOMES WITH INCREASING AGE IN TWIN PREGNANCIES AT A TERTIARY CARE HOSPITAL.

Background; Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources which translate into insufficient care during pregnancy and delivery. Due to inherent biological factors, twin pregnancies have increased rates of obstetric and perinatal complications such as preeclampsia, post-partum haemorrhage and preterm birth, which are known risk factors for maternal and perinatal mortality. Objective; To determine the frequency of adverse fetomaternal outcome in twin pregnancy in women of advanced age. Material and methods: A total of 181 patients with dichorionic diamniotic twin pregnancy on ultrasound having gestational age more than 24 weeks were taken in this cross-sectional study. Demographic information of patients (name, age, weight) was taken. Informed consent was taken from each patient, ensuring confidentiality and fact that there is no risk involved to the patient while taking part in this study. An obstetrical ultrasonography was done to confirm twin pregnancy. Blood samples were taken from all patients for assessment of anemia. Patients were followed up until pregnancy outcome. Results; Mean age of these study cases was noted to be 34.35 ± 2.41 years. Mean gestational age of our study cases was 34.67 ± 2.25 weeks. Mean BMI of our study cases was noted to be 22.45 ± 1.67 kg/m 2 (with minimum BMI was 19.4 kg/m 2 and maximum BMI was 32 kg/m 2 ) and obesity was present in 27 (14.9 %) of our study cases. Of these 181 study cases, 126 (69.6%) delivered vaginally while 55 (30.4%) had to undergo cesarean section delivery. Mean hemoglobin level was noted to 8.67 ± 1.40 g/dl while anemia was seen in 126 (69.6%) of these study cases. Preterm labor was observed in 144 (79.6%), abruptio placentae in 19 (10.5%) and low birth weight in 123 (68 %) of our study cases. Conclusion; Twin pregnancy is associated with high risk of perinatal and pregnancy outcomes. There was higher frequency of anemia, cesarean section deliveries, preterm births and low birth weight babies in our study. There is a need for specialised prenatal care to reduce complications and adverse outcome in multiple pregnancies, and the need for ongoing social and medical care beyond the prenatal and perinatal periods to improve perinatal outcomes in these patients. Keywords; Preterm labor, anemia, twin pregnancy. DOI : 10.7176/JMPB/58-04 Publication date : August 31 st 2019

Understanding Long-Term Cancer Survivors’ Preferences for Ongoing Medical Care

Due to risk for treatment-related late effects and concerns about cancer recurrence, long-term cancer survivors have unique medical needs. Survivors' preferences for care may influence adherence and care utilization. To describe survivors' preferences for care and factors associated with preferred and actual care. Cross-sectional analysis of participants in a longitudinal study using mailed questionnaires. Survivors of ten common cancers (n = 2,107, mean years from diagnosis 8.9). (1) Survivors' preferences for primary care physician (PCP) and oncologist responsibilities across four types of care: cancer follow-up, cancer screening, preventive health, and comorbid conditions. (2) Survivor-reported visits to PCPs and oncologists. The response rate was 42.1%. Most long-term survivors preferred PCPs and oncologists share care for cancer follow-up (63%) and subsequent screening (65%), while preferring PCP-led preventive health (77%) and comorbid condition (83%) care. Most survivors (88%) preferred oncologists involved in cancer follow-up care, but only 60% reported an oncologist visit in the previous 4years, and 96% reported a PCP visit in the previous 4years. In multivariable regressions, those with higher fear of cancer recurrence were less likely to prefer PCP-led cancer follow-up care (OR = 0.96, CI = 0.93-0.98), as did survivors with advanced cancer stage (OR = 0.56, CI = 0.39-0.79). Those with higher fear of recurrence (OR = 1.03, CI = 1.01-1.04) or who preferred oncologist-led cancer follow-up care (OR = 2.08, CI = 1.63-2.65) had greater odds of seeing an oncologist in the last 4years. Most cancer survivors preferred PCPs and oncologists share care for cancer follow-up and screening, yet many had not seen an oncologist recently. Survivors preferred PCP-led care for other preventive services and management of comorbid conditions. These findings highlight the important role PCPs could play in survivor care, suggesting the need for PCP-oriented education and health system policies that support high-quality PCP-led survivor care.

A preliminary study of efficacy of yoga therapy in anxiety disorders

Anxiety disorders are the most common of all mental health problems and often are chronic requiring ongoing medical or psychiatric care, including psychosocial therapies. Some of the non drug therapies such as Cognitive-behavioral therapy, Relaxation techniques, and bio- feed-back have proved efficacious. There has been a paucity of research on the role of yoga on anxiety disorders. Present paper examines the efficacy of yoga therapy in Anxiety Disorders and this is the preliminary findings of a long term project. Fifteen patients diagnosed suffering from Anxiety disorders (Panic Disorder, Generalized Anxiety Disorders) according to ICD-10 aged between 20 to 50 years, male and female; mild-moderate categories were recruited and assessed on anxiety severity scale. 6 males and 9 females were randomly assigned to one of the three groups – medication only; medication + yoga; and yoga only. Psychological General Well-Being Schedule, Satisfaction with Life, Anxiety Status Inventory, and Hamilton Anxiety Scale were administered. The physiological parameters such as pulse rate, respiratory rate, blood pressure, temperature, oxygen saturation, Body Mass Index were measured at base-line. A package of yoga practices designed to suit patients suffering from anxiety disorders was given. Patients were reassessed at 2 weeks, 6 weeks and at three months. Result showed significant improvement in Medicine+Yoga group while comparing with Medicine only group and Yoga only group. Even though the sample size is small, a combination of medication and yoga therapy reduced anxiety scores indicating the stabilization of mental imbalance.

Health and Psychosocial Needs of Older Adults Who Are Experiencing Homelessness Following Hospital Discharge.

Though hospitals are a common location where older adults experiencing homelessness receive health care, an understanding of the types of supports needed upon hospital discharge is limited. We examined the unique characteristics of older homeless adults and the health and psychosocial supports required upon hospital discharge. Guided by principles of community-based participatory research (CBPR), we conducted 20 in-depth, semi-structured interviews with shelter/housing and health care providers in Metro Vancouver. Thematic analyses revealed 6 themes: (a) older people experiencing homelessness have unique vulnerabilities upon hospital discharge; (b) following hospital discharge, general population shelters are inappropriate for older adults; (c) shelter/housing options for older adults who have complex health and social needs are limited; (d) shelter/housing for older adults who require medical stabilization and convalescence after hospital discharge is needed; (e) a range of senior-specific shelter/housing options are needed; and (f) unique community supports are needed for older adults upon hospital discharge. As the population of older adults increases across North America, there is a parallel trend in the increased numbers of older adults who are experiencing homelessness. Not only is there often a need for ongoing medical care and respite, but there is a need for both shelter and housing options that can appropriately support individual needs.

Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis.

Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital's emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States. This study describes the LWBS population at a multi-hospital academic health system. This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed. During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period. LWBS patients are high ED utilizers who may be effectively targeted by "hotspotting." Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.

Perspectives of Chinese Cancer Patients Toward Disclosure of Cancer Diagnosis to Their Minor Children.

One of the issues that cancer patients with minor or adolescent children face is whether to inform children about their cancer diagnosis. Their perspectives toward this issue are underexplored in China. The aim of this study was to explore Chinese cancer parents' perspectives toward informing children of their diseases. Eighteen cancer patients with children younger than 18 years were recruited using purposive sampling. Semistructured, face-to-face, in-depth interviews were conducted using a phenomenological approach. Data were analyzed using Colaizzi's approach. Six main themes with 2 to 6 subthemes emerged: (a) inappropriate to disclose the true diagnosis to children, (b) appropriate to disclose the true diagnosis to children, (c) communication content between cancer patients and their children in regard to cancer, (d) attitude on ways of disclosing cancer diagnosis to children, (e) reflections on parenting style, and (f) unmet needs for information and support. Perspectives of Chinese cancer parents toward truthfully disclosing their diagnosis vary, but all are for the purpose of protecting their children. Study findings indicate that Chinese cancer parents have culture-specific considerations, such as concepts of death and filial piety, which differ from studies in Western countries. Meanwhile, there are barriers between cancer parents and children in communicating about the illness and unmet needs for information and support. Psychosocial assessments and consultations, education, and interventions need to include a focus on the dependent children of adult cancer parents.

Feasibility of telephone-administered interviews to evaluate long-term outcomes of trauma patients in urban Ethiopia

BackgroundLittle is known about long-term functional outcomes of trauma patients in low-income and middle-income countries. In sub-Saharan Africa most studies of injury only collect data through emergency department disposition or...

Common Questions and Misconceptions in the Management of Renal Transplant Patients: A Guide for Health Care Providers in the Posttransplant Setting.

Once renal transplant recipients are stabilized and require less frequent follow-up with their transplant team, health care providers outside of the transplant setting play an integral role in patients' ongoing medical care. Given renal transplant recipients' inherent complexity, these health care providers often seek consult regarding decisions that may affect transplant-related medications or outcomes. In this review, we discuss answers to 10 of the questions commonly posed to our renal transplant team by other health care providers.