Primary Medical Condition Research Articles

Prevalence of oral diseases in patients under palliative care: a systematic review and meta-analysis.

Oral alterations are frequently observed in patients undergoing palliative care and are linked to the direct or indirect effects of the primary medical condition, comorbidities and medical management, leading to oral pain, impacting oral intake, and affecting quality of life. This systematic review aims to assess the prevalence of oral disease in palliative care patients. The protocol was registered at the PROSPERO database, and a systematic review of the literature was performed based on the PRISMA statement. A thorough evaluation of studies from five databases and gray literature was conducted. The risk of bias in each study was assessed using the Joanna Briggs Institute checklist for cross-sectional and case-control studies. A quantitative analysis was conducted on five studies using meta-analysis, and the degree of certainty in the evidence was determined using the GRADE tool. The sample consisted of 2,502 patients, with a slight male predominance (50.43%). The average age was 66.92years. The prevalence of oral diseases among palliative care patients was as follows: caries 32% (95% CI, 0.11-0.56; I2 = 93%), and oral candidiasis 17% (95% CI,0.11-0.25; I2 = 74%). Gingivitis and stomatitis were also reported, but with less frequency. Dental intervention should take place as early as possible, ideally from the time of the patient's initial admission to palliative care, with regular monitoring of oral health. This approach can enhance the patient's comfort and quality of life and help prevent more severe complications in the future.

Risk Factors for Perinatal Arterial Ischemic Stroke: A Machine Learning Approach.

Perinatal arterial ischemic stroke (PAIS) is a focal vascular brain injury presumed to occur between the fetal period and the first 28 days of life. It is the leading cause of hemiparetic cerebral palsy. Multiple maternal, intrapartum, delivery, and fetal factors have been associated with PAIS, but studies are limited by modest sample sizes and complex interactions between factors. Machine learning approaches use large and complex data sets to enable unbiased identification of clinical predictors but have not yet been applied to PAIS. We combined large PAIS data sets and used machine learning methods to identify clinical PAIS factors and compare this data-driven approach with previously described literature-driven clinical prediction models. Common data elements from 3 registries with patients with PAIS, the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and a longitudinal cohort of healthy controls (Alberta Pregnancy Outcomes and Nutrition Study), were used to identify potential predictors of PAIS. Inclusion criteria were term birth and idiopathic PAIS (absence of primary causative medical condition). Data including maternal/pregnancy, intrapartum, and neonatal factors were collected between January 2003 and March 2020. Common data elements were entered into a validated random forest machine learning pipeline to identify the highest predictive features and develop a predictive model. Univariable analyses were completed post hoc to assess the relationship between each predictor and outcome. A machine learning model was developed using data from 2,571 neonates, including 527 cases (20%) and 2,044 controls (80%). With a mean of 21 features selected, the random forest machine learning approach predicted the outcome with approximately 86.5% balanced accuracy. Factors that were selected a priori through literature-driven variable selection that were also identified as most important by the machine learning model were maternal age, recreational substance exposure, tobacco exposure, intrapartum maternal fever, and low Apgar score at 5 minutes. Additional variables identified through machine learning included in utero alcohol exposure, infertility, miscarriage, primigravida, meconium, spontaneous vaginal delivery, neonatal head circumference, and 1-minute Apgar score. Overall, the machine learning model performed better (area under the curve [AUC] 0.93) than the literature-driven model (AUC 0.73). Machine learning may be an alternative, unbiased method to identify clinical predictors associated with PAIS. Identification of previously suggested and novel clinical factors requires cautious interpretation but supports the multifactorial nature of PAIS pathophysiology. Our results suggest that identification of neonates at risk of PAIS is possible.

The importance of collaboration in maternal medicine: A retrospective descriptive study of a maternal multidisciplinary team meeting.

In the present study we aimed to review the evolution and function of the maternal medicine multidisciplinary team (MMMDT) meeting of a maternal medicine service of a tertiary level stand-alone maternity hospital. We conducted a retrospective descriptive study of all minutes of MMMDT meetings from 2014 to 2020, with the aim of evaluating meeting characteristics and patient demographics. There were 575 multidisciplinary team (MDT) discussions of 486 women during 43 meetings in the 7 year period. On average, 13 (range 3-23; SD = 5.28) women were discussed at each meeting, attended by 17 (range: 11-27; SD = 4.26) attendees. There were 18 women discussed during successive pregnancies. When analyzing the 2017-2020 data, preconceptual discussions made up 7.3% (n = 42) of patients discussed, with 5.7% (n = 33) being postnatal. The mean maternal age was 32.5 years (range 15-48 years) and women were most likely to be discussed in the mid-trimester period (21-24 weeks gestation). The top five primary specialities involved were hematology, neurology, rheumatology, neurosurgery and gastroenterology; however, 22 specialities were represented overall when classified by the primary medical condition. When examining the MDT input, hematology input was required in 144 patients (25.0%), radiology in 161 (28.0%) patients, and 117 in anesthesiology (20.3%). When examining the number of teams required to manage the patient, 80 women required the input of three specialities, with 16 women requiring the input of four specialities. We demonstrate the value and role of the MDT in the management of complex patients, providing a forum to discuss care in all phases of the obstetric journey.

1426. Characterization of Patients with Iatrogenic Mycobacterial Infections: A Hospital-Based Survey

Abstract Background Tuberculosis (TB) is a chronic granulomatous inflammation usually involving the lung parenchyma and hilar lymph nodes. Extra-pulmonary involvement is seen in ∼20% of all TB cases. Developing tuberculosis following treatment for another primary medical condition is a rare occurrence. Iatrogenic literally means illness caused by medical examination or treatment. Mycobacteria have been used to treat a few medical conditions and the therapeutic use has been validated extensively in literature. The mycobacteria used for therapeutic purposes are supposed to be either attenuated or non pathogenic strains. Growth and dissemination of this mycobacterium is a rare but serious possibility. Reactivation of latent mycobacterial infection following therapy is also a part of iatrogenic mycobacterial infection. Methods We report a retrospective study investigating adverse events manifesting with development of iatrogenic tuberculosis. The data was obtained from a tertiary care centre over a period of 2 years. Diagnosis of tuberculosis was established based on clinical, radiological(chest X-Ray and High resolution CT scan), sputum smear microscopy and skin/tissue biopsy and Xpert MTB/RIF. Tuberculin skin test(TST) and Interferon gamma release assay (IGRA) were used as additional diagnostic tests. Results The search yielded 26 cases of iatrogenic tuberculosis, with a median age of 56.5 years. Most common cause was reactivation of latent tuberculosis due to use of anti-TNF alpha biologic agents(53.8%). Development of Tuberculosis verrucosa cutis following BCG inoculation for verruca vulgaris was noted in about 19.2% of cases and Tubercular abscess due to Mycobacterium w or BCG inoculation for Covid-19 was noted in 11.5% cases. Bacillus Calmette Guérin(BCG) induced balanitis secondary to therapy for Carcinoma urinary bladder was noted in 7.69%of cases. Bacillus Calmette-Guerin or BCG induced balanitis following use of intravesical immunotherapy for treating early-stage urinary bladder cancer and successful clearance of lesions post therapy Tuberculosis Verrucosa Cutis following Immunotherapy for plantar warts Conclusion All patients were managed successfully with anti tubercular therapy. These observations indicate that tuberculosis infection can develop in previously healthy individuals in endemic zones following biologic therapy of use of mycobacterial agents for other therapeutic indications. Disclosures All Authors: No reported disclosures.

Who receives post-acute care? Characteristics of national population and field test sample.

Each year millions of Medicare beneficiaries in the United States receive post-acute care (PAC) in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies (HHA). We describe, overall and by PAC setting, the national population of facilities and patients, evaluate the representativeness of a national field test sample, and describe patient characteristics in the national field test sample. We analyzed the 2016 Provider of Service file, 2016 patient assessment data reported by PAC providers to Centers for Medicare & Medicaid, and data collected from PAC providers participating in a national field test. National data included 27,234 PAC settings and 5,033,820 beneficiaries receiving PAC. The national field test sample consisted of 143 facilities across 14 markets with 25-30 patients sampled from each facility (n=3669). We describe PAC facility and patient characteristics for both the national and field test sample. Nationally, PAC facilities were more likely for-profit versus not for-profit, have an average nurse-to-bed ratio between 1:10 to 1:1 (lowest in SNFs) and be in metropolitan versus other areas. PAC patients were more likely to be white, female, and 75-89 years of age; heart failure as a primary medical condition tended to be more common than stroke or sepsis. There was limited variability across setting types. In the national field test, patients in LTCHs demonstrated a greater likelihood of cognitive impairment, positive depression screening, bowel and bladder appliance use, higher rates of medication drug classes taken, and use of therapeutic diets and IV medications. The national field test facility and patient samples were fairly representative of the national population overall and across settings with a few exceptions. Moreover, differences according to PAC setting on patient characteristics in the national field test aligned with general differences in patient populations.

Creating a standard inpatient opioid withdrawal protocol.

Background: Despite safety and efficacy of medications for opioid use disorder, United States (US) hospitals face high health care costs when hospitalized patients with opioid use disorder (OUD) leave due to untreated opioid withdrawal. Recent studies have concluded that evidence-based interventions for OUD like buprenorphine are underutilized by hospital services. Objective: We developed a practical opioid withdrawal protocol utilizing buprenorphine and the Clinical Opiate Withdrawal Scale to address opioid withdrawal during inpatient treatment of a primary medical condition. We are currently implementing this protocol at the UCLA hospital in Santa Monica. Design: The protocol includes order sets with appropriate and modifiable orders that can be submitted in the electronic medical record in order to deliver seamless care for opioid withdrawal. After the physician assesses the patient and initiates the protocol, nursing provides an essential role in continuing to monitor the patient's level of withdrawal and administering the appropriate medications in response. Inpatient pharmacy is instrumental in monitoring medication administration, as well as calculating and providing dosages for orders on Day 2 and 3 of the protocol. Collaboration with case managers is essential for providing appropriate resources and ensuring a safe discharge. Conclusion: Current challenges to widespread implementation of a standardized withdrawal protocol are discrepancies in addiction education across medical disciplines and inadequate outpatient access to buprenorphine providers and pharmacies that carry buprenorphine supplies.

Abstract 11728: Common Primary Medical Conditions Associated With Secondary Takotsubo Cardiomyopathy

Introduction: Secondary Takotsubo cardiomyopathy (TCM) is considered a complication of the patient’s primary medical condition, such as medical, surgical or psychiatric conditions. More than one-third of TCM patients have primary medical conditions and tend to have a worse prognosis. However, there is no comprehensive study on the causes of TCM. Aim: We studied the common primary medical conditions in secondary TCM patients and their prognosis. Methods: We performed a retrospective analysis using the ICD-10-CM codes for a secondary diagnosis of TCM from the National Inpatient Sample database (2016-2018). We identified the primary medical condition represented by the ICD-10-CM diagnosis codes of secondary TCM patients and aggregated similar codes into clinically meaningful categories using the Clinical Classifications Software Refined. We then compared the mortality rate associated with each condition. Results: Of 14,816 patients admitted with secondary TCM, the common primary medical conditions included ‘Sepsis, unspecified organism’ (A419, 13.6%), ‘Chronic obstructive pulmonary disease with (acute) exacerbation’ (J441, 3.6%), ‘Acute respiratory failure with hypoxia’ (J9601, 2.8%), and ‘Pneumonia, unspecified organism’ (J189, 1.8%). After aggregating the individual codes into clinical categories, the common primary medical conditions included septicemia (19.1%), respiratory failure (6.4%), COPD and bronchiectasis (4.6%), hypertension with complications and secondary hypertension (4.2%), and cerebral infarction (3.1%). Primary medical conditions that yielded a higher mortality rate than the overall rate (8.5%) were septicemia (16.5%, P<0.001), respiratory failure (10.7%, P=0.019), cerebral infarction (13.1%, P<0.001), and acute hemorrhagic cerebrovascular disease (26.8%, P<0.001). Conclusions: Sepsis is the most common primary medical condition of secondary TCM in admitted patients. Secondary TCM patients with a primary condition of acute hemorrhagic cerebrovascular disease, sepsis, respiratory failure, or cerebral infarction have higher in-hospital mortality than those with other primary medical conditions.

Prevalence of delirium among older adults in a tertiary care referral hospital in Kerala

Background: Delirium is a common neuropsychiatric condition in older adults in medical and surgical settings. It is important to identify cognitive impairment in the elderly population early in their stay at the hospital to reduce morbidity and mortality. The literature on the prevalence of delirium in the elderly population shows that the occurrence of delirium is associated with patient factors and clinical settings. Delirium may affect the outcome of the primary medical condition in addition to the occurrence of poor compliance to treatment and long-term psychological sequela. Aim: The study aims to identify the prevalence of clinical delirium among patients at the age of 60 years or above, admitted in medical and surgical units of Government Medical College Hospital, Kozhikode, Kerala. The study also looked into the related factors and management aspects of the condition. Methods: A cross-sectional observational method was used in a sample of 300 older adult patients who were selected using a census approach from medical and surgical inpatient units of the hospital. Clinical and personal details were collected in addition to the assessment of the participants with the Confusion Assessment Method (CAM) and Nursing Delirium Screening Scale(Nu-DESC). Results: Findings of the study revealed the prevalence of delirium in older adult patients at 16%. The study also shows a significant association between the prevalence of delirium and selected clinical variables and area of admission. Conclusion: Early identification and prompt medical and psychiatric care, and environmental manipulation will reduce the development of complications in older adults.

Changes in Access to Australian Disability Support Benefits During a Period of Social Welfare Reform

AbstractThe Disability Support Pension (DSP) is the major Australian government financial benefit program for people of working age with medical conditions and disabilities that restrict work capacity. Between 2012 and 2018 a series of policy reforms sought to restrict the growth in DSP payments and encourage more people with some work capacity to seek employment. We characterise changes in three markers of access to disability financial support over the reform period (1) DSP recipient rates (2) DSP grant (approval) rates and (3) the rate of unemployment benefit receipt in people with impaired work capacity. Results demonstrate a significant reduction in DSP receipt and grant rates, and significant increase in the rate of unemployment benefit receipt in working-age Australians with work disabling medical conditions and disability. These changes were not distributed uniformly. People whose primary medical condition was a musculoskeletal or circulatory system disorder demonstrated greater declines in DSP receipt and grant rates, while there was a more rapid increase in unemployment benefit receipt among people with primary mental health conditions. Some trend changes occur in periods during which new disability assessment and pension eligibility policies were introduced, though our ability to attribute changes to specific policy changes is limited.

Candida auris Infection Among Patients With Cancer in an Oncology Center in Eastern India

Background: The multidrug-resistant fungus Candida auris is emerging as a major cause of healthcare-associated infection globally. Understanding the epidemiology of these infections in vulnerable groups such as cancer patients is important for hospital infection control and their effective management. In this report we present diagnostic, clinical, antifungal resistance and outcome data of 11 cases of C. auris infection from an oncology center in India. Methods:C. auris strains were identified by Sanger-based DNA sequencing of the internal transcriber spacer (ITS) gene. Antifungal susceptibility testing (AFST) was performed using the broth dilution method. Identification and AFST were checked by the WHO Collaborating Center for Reference & Research on Fungi of Medical Importance. Patients had both empirical as well as directed therapy with antifungal agents based on AFST results and clinical assessment. Results: Between November 2018 and March 2019, 11 cases of C. auris (8 from patients with solid-organ tumors and 3 from hematological malignancy) were detected. Two distinct genetic clusters were identified by ITS gene sequencing; one of these clusters showed 100% homology with a previously unknown C. auris isolate (GenBank accession no. MK881076) and the other cluster had a 100% identity score with isolates from Japan and South Korea (GenBank accession nos. MH071441, KY657027, and EU884189). All 11 strains were resistant to fluconazole. With voriconazole, 1 isolate was susceptible, 3 were resistant, and 7 showed dose-dependent susceptibility. Two isolates were resistant to amphotericin B. Resistance to caspofungin or anidulafungin was noted in 1 of 11 isolates (9%); most showed intermediate susceptibility (63% to caspofungin). Among all of the patients, 72% were from the intensive care unit (ICU) or the high-dependency unit. The 30-day all-cause mortality was 5 of 11 (45%) in the C. auris group and 4 of 11 (36%) the control group (ie, infections with other Candida spp during same period). Duration of ICU stay in the C. auris group was 12 days and in the control group it was 6 days. The median cost (in terms of hospital bill at the time of discharge or death) for management of Candida auris infection and the primary medical condition was US$10,121 for the C. auris groups and US$8,608 for the control group. Most cases (10 of 11) were detected in wards without isolation rooms, and 8 of the 11 C. auris cases (73%) were detected in patients in the intensive care unit. Conclusions: Morbidity, mortality, ICU stay, and healthcare costs are significant in C. auris infection.Funding: NoneDisclosures: None

Hospitalized Medical Patients With Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care.

Posttraumatic stress disorder (PTSD) is common in the United States, with a prevalence of nearly 8% in the general population and between 10% and 30% in veterans. Despite how common PTSD is, inpatient providers may not be familiar with its manifestations or feel comfortable taking care of patients who may exhibit symptoms related to it. In our combined experience as VA-based hospital medicine care providers, we have cared for thousands of patients hospitalized for a primary medical condition who also have PTSD as a comorbidity. We have noticed in our practices that we only focus our attention on PTSD if a related problem arises during a patient's hospitalization (eg, confrontations with the care team or high levels of anxiety). We contend that a more proactive approach could lead to better care, but little evidence about best practices exists to inform the interdisciplinary team how to optimally care for hospitalized medical patients with PTSD. In this narrative review, we present a synthesis of existing literature, describe how trauma-informed care could be used to guide the approach to patients with PTSD, and generate ideas for changes that inpatient providers could implement now, such as engaging patients to prevent PTSD exacerbations and promoting better sleep in the hospital.

Female Hypoactive Sexual Desire Disorder: A Practical Guide to Causes, Clinical Diagnosis, and Treatment.

Hypoactive sexual desire disorder (HSDD) in women is defined as the persistent or recurrent absence of sexual thoughts or fantasies and/or lack of desire for sexual activity that is associated with marked personal distress and/or interpersonal difficulties, and cannot be better attributed to another primary disorder, medication, or general medical condition. Notably, HSDD shares some similarity with depression, as its etiology can be explained using a biopsychosocial model that includes biological, psychological, and sociocultural factors, as well as interpersonal influences. Due to its high prevalence and negative impact on the overall health and well-being of women, primary care health professionals and women's health practitioners need to be actively aware of HSDD, particularly because patients may be reluctant or unwilling to initiate a discussion about their sexual concerns during routine visits. HSDD is well established as a valid and treatable clinical entity. Even for those inexperienced in treating sexual problems, there are simple and validated screening tools such as the Decreased Sexual Desire Screener that can help identify HSDD and a need for further evaluation and treatment. There have been few established pharmacologic treatments for HSDD. Flibanserin was the first drug approved for the treatment of HSDD by the U.S. Food and Drug Administration (FDA). Bremelanotide, a novel melanocortin receptor agonist, was recently approved by the FDA for the treatment of acquired, generalized HSDD in premenopausal women. Increased awareness and recognition of HSDD as a medical condition should provide an incentive for further clinical development of effective treatments for HSDD.

Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting.

A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. This retrospective analysis (N=61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n=36) and post-implementation (n=25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts. Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P= 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8±22.2% vs 55.9±24.0%; P= 0.01) and energy requirements (93.4±36.9% vs 69.6±35.3%; P= 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition). Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.

SUN-038 RECOVERY OF KIDNEY FUNCTION IN GLOMERULONEPHRITIS WITH RAPIDLY PROGRESSIVE RENAL FAILURE AT CHO RAY HOSPITAL

It is uncommon for patients with glomerulonephritis (GN) who require hemodialysis (HD) to recover renal function. Lupus nephritis (LN) is one of the common GN in Vietnam. Our aim was to describe the renal outcome of 64 GN patients with rapidly progressive renal failure (RPRF) on HD at Cho Ray Hospital, Ho Chi Minh City, Vietnam. A prospective study was conducted in 64 GN patients with RPRF requiring HD from 2014 to 2018. RPRF was defined as a progression to renal failure within a period of 1 week to three months. A definitive diagnosis of the kidney disease was established by history, clinical examination, lab tests, and renal biopsy. The patients had received standard therapy for their primary medical condition. We followed the patients after initiation of HD (3 months min, 18 months max) to evaluate recovery sufficient to discontinue HD Patient median age 25 (Inter-quartile range 21,32); 49 females; 59/64 pts with lupus nephritis (LN) (54 class III or IV, 1 class V, and 1 unclassified). 3 patients had IgA nephropathy; 1 Anti-glomerular basement membrane GN; 1 idiopathic membranoproliferative GN. Thrombotic microangiopathy (TMA) was clinically diagnosed based on Coombs negative hemolytic anemia, thrombocytopenia, D-Dimer >600 ng/mL, LDH >600 U/L, schistocytes on blood smear, with or without kidney biopsy. TMA was found in 56 pts, of which 19 were biopsy proven. Six LN patients with TMA were tested for ADAMTS13, all of whom were negative. Patients with TMA were treated with therapeutic plasma exchange (26 cases) or plasma infusion (30 cases) and heparin anticoagulation. All 64 pts were on oral methylprednisolone (median 32mg/day, IQR 16, 48mg) for the first month then tapered. 41 pts (39 LN, 2 non Lupus GN) received median of 6 doses of monthly intravenous cyclophosphamide 0.5g/m2 over median 12 months follow up. 36/59 (61%) of LN pts recovered kidney function, and discontinued HD after median 39 days (IQR 24;72 days). They remained dialysis independent for a median of 10 months (IQR 6 ,11 months) follow up. Median of the last serum creatinine in patients who recovered function was 1.4 mg/dL (IQR 1.2; 1.7 mg/dL). In the 28 patients who failed to recover kidney function, 4 died and 24 continued HD after median 4 months. Recovery of renal function was more common in LN pts with TMA or patients with length on HD of less than 3. Recovery of function was not associated with age, gender, body mass index, hypertension, 24h proteinuria, hematuria, isolated TMA diagnosis, anemia, or serum albumin on admission). TableComparison between patients who recovered and failed to recover functionTotal (N=64)Recovered kidney function (N=36)Non recovered kidney function (N=28)pLupus nephritis5936 (61%)230.03Nonlupus GN50 (0%)5TMAneg/LNpos85 (62.5%)30.01TMApos/LNpos5131(60.7%)20TMApos/LNneg50(0%)5Length on HD ≤ 3 months4632(69.5%)140.005Length on HD > 3 months184(22.2%)14 Open table in a new tab RPRF in lupus nephritis patients with or without TMA had a good likelihood of function recovery after requiring hemodialysis.

Prevalence and correlates of medical cannabis patients' use of cannabis for recreational purposes

BackgroundRates of legal medical cannabis (MC) use are increasing, but little is known about the prevalence and correlates of recreational cannabis (RC) use among medical users (MC/R). Methods348 MC users who resided in a state in which MC is legal and had medical authorization to use MC legally completed an anonymous survey in Spring 2017 (64.1% female, 82.8% White, mean age 33.03[±10.37] years). Rates of endorsing MC/R and the following potential correlates of MC/R were examined: the legal status of RC in participants' states of residence, sex, age, race, primary medical condition, MC product(s) used, MC expectancies, features of MC sought out (e.g., high tetrahydrocannabinol [THC] content), and negative cannabis use consequences. Results55.5% of MC users engaged in MC/R. MC/R was associated with residing in a state in which RC is legal, being female, using MC for pain or mental health conditions, vaping MC concentrates, holding positive expectancies for combustible MC, and seeking out MC products with high THC concentrations. Preferring MC products with high cannabidiol (CBD) concentrations protected against MC/R. ConclusionsMore than half of MC users endorsed MC/R, which is considerably higher than rates of misuse observed for other prescription medications. Findings raise concerns about circumvention of RC laws in states where RC remains illegal and could be used to inform MC regulatory efforts (e.g., reducing THC content, increasing CBD content). Findings also suggest that prevention/intervention efforts to reduce MC/R are needed, especially among high-risk populations of MC users (e.g., women, pain patients, psychiatric patients).

Longitudinal changes in clinical characteristics and outcomes for children using long-term non-invasive ventilation.

ObjectivesTo describe longitudinal trends in long-term non-invasive ventilation (NIV) use in children including changes in clinical characteristics, NIV technology, and outcomes.MethodsThis was a multicenter retrospective cohort of all children started on long-term NIV from 2005 to 2014. All children 0 to 18 years who used NIV continuously for at least 3 months were included. Measures and main outcomes were: 1) Number of children starting NIV; 2) primary medical condition; 3) medical complexity defined by number of comorbidities, surgeries and additional technologies; 4) severity of sleep disordered breathing measured by diagnostic polysomnography; 5) NIV technology and use; 6) reasons for NIV discontinuation including mortality. Data were divided into equal time periods for analysis.ResultsA total of 622 children were included in the study. Median age at NIV initiation was 7.8 years (range 0–18 years). NIV incidence and prevalence increased five and three-fold over the 10-year period. More children with neurological and cardio-respiratory conditions started NIV over time, from 13% (95%CI, 8%-20%) and 6% (95%CI, 3%-10%) respectively in 2005–2008 to 23% (95%CI, 18%-28%) and 9% (95%CI, 6%-14%, p = 0.008) in 2011–2014. Medical complexity and severity of the sleep-disordered breathing did not change over time. Overall, survival was 95%; mortality rates, however, rose from 3.4 cases (95% CI, 0.5–24.3) to 142.1 (95% CI 80.7–250.3, p<0.001) per 1000 children-years between 2005–2008 and 2011–2014. Mortality rates differed by diagnostic category, with higher rates in children with neurological and cardio-respiratory conditions.ConclusionsAs demonstrated in other centers, there was a significant increase in NIV prevalence and incidence rate. There was no increase in medical complexity or severity of the breathing abnormalities of children receiving long-term NIV over time. The mortality rate increased over time, maybe attributable to increased use of NIV for children with neurological and cardio-respiratory conditions.

Oral health in children with special needs

Background/Aim. Due to their primary medical condition, children with special needs often display lower levels of oral hygiene, larger prevalence of caries and other oral diseases. The aim of this study was to estimate the prevalence of dental caries, oral cleanliness and presence of malocclusion in children with disabilities, as well as to evaluate eruption time of the permanent molars. Methods. Case?control study was carried out on a group of 107 children with disabilities at the Faculty of Dental Medicine, University of Belgrade, Serbia. The control group comprised of 104 healthy school children. Results. Children with disabilities had statistically higher mean [decayed missing and filled teeth ? dmft for primary DMF for permanent dentition (dmft DMFT)] values in both dentitions than children from the control group (p &lt; 0.05). Oral cleanliness level was much lower in children with disabilities. A significantly higher percentage of Class II malocclusions and a higher tendency to have a delayed time of eruption of permanent molars were observed in the test group in permanent dentition. Conclusion. Considering poor oral health status and higher tendency for development of malloclusions and delayed eruption, it is necessary to develop preventive dental programmes for children with special needs, as well as improve public awareness about these issues.

Predictors of Caregiver Burden among Mothers of Children with Chronic Conditions.

Objective: The complex medical regimens of children and adolescents with chronic conditions can have a significant impact on families and households. Caregivers may experience burden, which can lead to negative health consequences and poor quality of life. The objective of this study was to determine child-related predictors and risk factors for caregiver burden among parents of children with chronic conditions. Methods: We distributed an institutional review board (IRB)-approved, online cross-sectional survey to parents of children who attended the Victory Junction therapeutic camp. Parents provided information on child demographics, disease characteristics, and healthcare utilization. Parents also answered the adapted Zarit Burden Interview, which measured caregiver burden. Children completed scales about self-management and self-efficacy. Linear regression analyses determined how children’s disease characteristics, health utilization, and self-management skills were associated with caregiver burden. Results: We enrolled 150 mother-child dyads. The mean age of child participants was 12.23 years (±2.5), with an age range of 6 to 16 years. It was determined that children’s number of medicines and injections (β = 0.161, p = 0.047), a diagnosis of attention-deficit/hyperactivity disorder (ADHD) in addition to the primary medical condition (β = 0.216, p = 0.008), frequent visits with a primary care provider (PCP) (β = 0.209, p = 0.026) and emergency room (ER) visits (β = 0.197, p = 0.038), and lower child self-efficacy (β = −0.241, p = 0.041) were predictors of increased caregiver burden. Conclusions: We identified risk factors for caregiver burden among mothers. Future studies should explore additional child-related characteristics as they relate to caregiver burden, and should determine if interventions for mothers of children with chronic conditions can lead to positive outcomes.

Psychiatric Disorders and Trends in Resource Use in Pediatric Hospitals

To describe recent, 10-year trends in pediatric hospital resource use with and without a psychiatric diagnosis and examine how these trends vary by type of psychiatric and medical diagnosis cooccurrence. A retrospective, longitudinal cohort analysis using hospital discharge data from 33 tertiary care US children's hospitals of patients ages 3 to 17 years from January 1, 2005 through December 31, 2014. The trends in hospital discharges, hospital days, and total aggregate costs for each psychiatric comorbid group were assessed by using multivariate generalized estimating equations. From 2005 to 2014, the cumulative percent growth in resource use was significantly (all P < .001) greater for children hospitalized with versus without a psychiatric diagnosis (hospitalizations: +137.7% vs +26.0%; hospital days: +92.9% vs 5.9%; and costs: +142.7% vs + 18.9%). During this time period, the most substantial growth was observed in children admitted with a medical condition who also had a cooccurring psychiatric diagnosis (hospitalizations: +160.5%; hospital days: +112.4%; costs: +156.2%). In 2014, these children accounted for 77.8% of all hospitalizations for children with a psychiatric diagnosis; their most common psychiatric diagnoses were developmental disorders (22.3%), attention-deficit/hyperactivity disorder (18.1%), and anxiety disorders (14.2%). The 10-year rise in pediatric hospitalizations in US children's hospitals is 5 times greater for children with versus without a psychiatric diagnosis. Strategic planning to meet the rising demand for psychiatric care in tertiary care children's hospitals should place high priority on the needs of children with a primary medical condition and cooccurring psychiatric disorders.

Deployment of the 1st Area Medical Laboratory in a Split-Based Configuration During the Largest Ebola Outbreak in History.

The U.S. Army 1st Area Medical Laboratory (1st AML) is currently the only deployable medical CBRNE (Chemical, Biological, Radiological, Nuclear, and Explosives) laboratory in the Army's Forces Command. In support of the United States Agency for International Development Ebola response, the U.S. military initiated Operation United Assistance (OUA), and deployed approximately 2,500 service members to support the Government of Liberia's Ebola control efforts. Due to its unique molecular diagnostic and expeditionary capabilities, the 1st AML was ordered to deploy in October of 2014 in support of OUA via establishment of Ebola testing laboratories. To meet the unique mission requirements of OUA, the unit was re-organized to operate in a split-based configuration and sustain four separate Ebola testing laboratories. This article is a review of the 1st AML's OUA participation in a split-based configuration. Topics highlighted include pre-deployment planning/training, operational/logistical considerations in fielding/withdrawing laboratories, laboratory testing results, disease and non-battle injuries, and lessons learned. Fielding the 1st AML in a split-based configuration required careful pre-deployment planning, additional training, optimal use of personnel, and the acquisition of additional laboratory equipment. Challenges in establishing and sustaining remote laboratories in Liberia included: difficulties in transportation of equipment due to poor road infrastructure, heavy equipment unloading, and equipment damage during transit. Between November 26, 2014 and February 18, 2015 the four 1st AML labs successfully tested blood samples from patients and oral swabs collected by burial teams in rural Liberia. The most significant equipment malfunction during laboratory operations was generators powering the labs, with the same problem impacting headquarters. Generator failures delayed laboratory operations/result reporting, and put temperature sensitive reagents at risk. None of the 22 1st AML soldiers (at remote labs or headquarters) had an Ebola exposure, none were infected with malaria or other tropical diseases, and none required evacuation from the time deployed to remote sites. The primary medical condition encountered was acute gastroenteritis, and within the first week of arrival to Liberia, 19 (86%) soldiers were affected. With proper planning and training, the 1st AML can successfully conduct split-based operations in an outbreak setting, and this capability can be utilized in future operations. The performance of the 1st AML during the current Ebola outbreak highlights the value of this asset, and the need to continue its evolution to support U.S. military operations.