Proactive Use Research Articles

Proactive external lumbar drainage use in pediatric idiopathic intracranial hypertension and proposal of a new treatment algorithm

Proactive external lumbar drainage use in pediatric idiopathic intracranial hypertension and proposal of a new treatment algorithm

Soil organic carbon and nitrogen reduction through cattle-path induced erosion in montane grasslands, KwaZulu-Natal, South Africa

The impact of daily cattle migration from homesteads to higher altitude pastures creates severe erosion in the montane grasslands of the predominantly subsistence agricultural rural communities of KwaZulu-Natal, Drakensberg, South Africa. This study quantifies the impact of a degraded cattle path at up, mid and downslope positions on SOC and N distribution in the soil profile and within the soil aggregates. An attempt to evaluate sites of erosion and deposition using excess lead-210 (210Pbex) to support our findings was conducted. On average, the degraded cattle path reduced SOC and N in the bulk soil (by 3–4 times, respectively) and was associated with 53% reduction in aggregate stability and a 14% increase in soil bulk density over the non-degraded reference site. These results reflect the loss of vegetation cover (correlated positively to SOC and N (r ≈ 0.94)), which were triggered by cattle grazing and trampling leading to top-soil loss. Cattle hoofs damage the grass and breakdown soil aggregates, exposing the fertile topsoil particles to detachment and consequential transportation via rill and sheet erosion. This is supported by the loss of 210Pbex in the topsoil of the degraded slope positions relative to the reference site. Consistent down core mixing of 210Pbex activity in degraded slope sites supports evidence of cattle mediated soil mixing. Our findings highlight the accelerated land degradation that results from uncontrolled grazing and movement of cattle on sloping lands in the Okhombe Valley. Developing an integrated management strategy co-led by local communities to develop proactive participatory sustainable land use practices is critical for long-term landscape maintenance and recovery in the region.

Recommendations for Improving Chronic Care in Times of a Pandemic Based on Patient Experiences

ObjectivesThe COVID-19 pandemic had a profound and pervasive impact on the health of chronic care patients and disrupted care systems worldwide. Our research aimed to assess the impact of the pandemic on chronic care provision and provide recommendations for improving care provision, based on patient experiences. DesignQualitative semi-structured interviews were held among patients with chronic obstructive pulmonary disease (COPD) or heart failure. Setting and ParticipantsUsing stratified sampling, 23 patients with COPD, heart failure, or both were recruited to participate in semi-structured interviews. In the summer of 2021, online interviews were conducted. MethodsAn iterative process was adopted to analyze the data. Going back and forth through the data and our analytical structure, we first coded the data, and subsequently developed categories, themes, and aggregate dimensions. The data were synthesized in a data structure and a data table, which were analyzed using an interpretative approach. ResultsWe found 3 dimensions through which care might be improved: (1) proactive and adaptive health care organization and use of innovative technologies, (2) assistance in maintaining patient resilience and coping strategies, and (3) health care built on outreaching and person-centered care enabling identification of individual patient needs. Experiences of impaired accessibility to care, altered and unmet care demands and patient needs, and the negative impact of national containment strategies on patient resilience support the need for improvement in these dimensions. Conclusions and ImplicationsThe in-depth insight gained on the impact of the pandemic on chronic care provision was used to propose recommendations for improving care, supported by not only the what and how but also the why developments require additional efforts made by policymakers and change agents, augmented by structural use and development of innovations. Health care organizations should be enabled to rapidly respond to changing internal and external environments, develop and implement innovations, and match care to patient needs.

Protocol for a randomized controlled trial to reduce pediatric anesthesia emergence delirium by titration of sevoflurane anesthesia using brain function monitoring

BackgroundEmergence agitation or emergence delirium is a common complication of unknown etiology in pediatric anesthesia. Pediatric anesthesia emergence delirium (PAED) has been reported most commonly in younger children and may occur in about 30% of children up to 5–6 years old. Exposure to anesthetic agents may contribute to PAED, and we hypothesized that a management strategy to minimize exposure to volatile anesthetics may reduce PAED. Electroencephalography (EEG) signatures captured and displayed by brain function monitors during anesthesia change with concentration of sevoflurane and level of unconsciousness, and these EEG signatures may be used to inform titration of anesthetics.MethodsA single-center, parallel-group, two-arm, superiority trial with a 1:1 allocation ratio will be performed to compare the incidence of PAED following standard sevoflurane anesthesia (maintained at 1.0MAC) and EEG-guided anesthesia (minimum concentration to sustain surgical anesthesia as determined by monitoring of EEG signatures). Participants between 1 and 6 years of age undergoing surgical procedures involving minimal postoperative pain will be randomly assigned to receive standard (n = 90) or EEG-guided (n = 90) anesthesia. PAED score will be assessed by a blinded observer in the PACU on arrival and after 5, 10, 15, and 30 min.DiscussionAnesthesia management with proactive use of brain function monitoring is expected to reduce exposure to sevoflurane without compromising surgical anesthesia. We expect this reduced exposure should help prevent PAED. Routinely administering what may be considered standard levels of anesthetic such as 1.0 MAC sevoflurane may be excessive and potentially associated with unfavorable sequelae such as PAED.Trial registrationJapan Registry of Clinical Trials (jRCT) jRCTs032210248. Prospectively registered on 17 August 2021.

Equity on the road in Uganda: How do interface bureaucrats integrate marginalized groups in the transport sector?

Research on road transport has paid growing attention to social equity objectives. However, little work has examined the role of the government officials that are charged to implement - notably how they make sense of and respond to mismatches between expectations and reality in their regulatory mandates. Drawing on a theoretical framing focused on interface bureaucracy and primary data from semi-structured interviews, this paper examines the agency of government officials in Kampala, Uganda. The analysis highlights how they take initiative to address social equity concerns, seeking to navigate implementation barriers through i) lobbying people in power, ii) seeking leverage in conditionalities of external funding, iii) alliance-building with civil society, and iv) proactive use of city level by-laws. This adds one of few empirical studies available on this subject within the transport studies literature and in the context of East Africa. It also offers a contribution towards conceptualizing what the agency of government officials might mean for the operationalization of key policy objectives in the transport sector.

Proactive use of intensive aversive conditioning increases probability of retreat by coyotes

AbstractCoyotes (Canis latrans) are showing increasingly bold behaviors toward people and their pets throughout North America. Bold behavior by wildlife might be reduced by hazing and aversive conditioning, which is recommended in many management plans for coyotes, but with little information about how it is to be conducted, and few studies have tested this approach. We conducted an online search for coyote management plans across North America to review techniques and recommendations related to the implementation of hazing or aversive conditioning and reported on the implementation of a high‐intensity aversive conditioning program in Calgary, Alberta, Canada. Almost all the management plans recommended hazing coyotes, most often by using a combination of noises, lights, and movements, but only 20% of 71 plans recommended high‐intensity techniques like those used by the contractors in Calgary. Contractors there searched for coyotes in 72 public park areas where members of the public had submitted reports to a civic call center for bold coyotes, attended sites on 1917 occasions, observed coyotes on 765 occasions, and reported coyote treatments and responses on 734 occasions. The probability of coyote retreats increased by 29%–37% with each additional previous aversive conditioning event at the site and doubled with the presence of dogs and with the application of projected chalk balls prior to the event being investigated, suggesting coyotes learned to avoid contractors. During engagements with contractors, coyote retreat probability declined by 21%–25% with each additional day since the last aversive conditioning engagement, and by 97.2%–97.6% with the presence of dogs and when shots were fired from a paintball gun, presumably because these tools were used only on the boldest coyotes. We found no effect of the presence or past number of aversive conditioning events on the number of coyote reports per week by the public. Although such high‐intensity aversive conditioning is rarely recommended in management plans, our results suggest that its repeated application can reduce coyote boldness over time, but coyotes may not generalize this response to other people owing to visual cues (e.g., high‐visibility vests, consistent vehicles) associated with contractors.

Flyrock Throw Calculations Unscientific and Unreliable – The “Hits” Just Keep on Coming

Flyrock is the dirty little secret of the aggregate industry and its explosives engineers, and they have been remarkably successful in concealing the potentially deadly consequences of flyrock from the public, while continuing to engage in reckless blasting practices based on theoretical guesswork rather than proven practical land use planning safeguards such as permanent (fixed) onsite setbacks (excavation limits) coupled with permanent offsite separation distances from existing and potential future sensitive land uses. Flyrock is an unavoidable by-product of blasting rock, and has the potential to damage personal or real property, injure, permanently disable or kill humans and non-humans, both onsite and offsite. Flyrock, along with other adverse effects such as vibrations, that leaves the boundaries of an aggregate operation, constitutes nuisance and trespass, and damage or injury caused by detonation of explosives, should be held to strict liability. Implementing proactive and forward-looking land use policies that safeguard existing and envisioned sensitive land uses from the potentially deadly consequences of detonation of explosives in aggregate extraction is the most effective way to protect the long-term health, safety and welfare of existing and future generations, and to avoid interfering with the use and enjoyment of third-party real property.

Coordinated Distributed Experiments in Higher Education: A Low Barrier to Entry and Potential for Student Projects

AbstractThis mixed‐methods research focused on the implementation of a coordinated distributed experiment (CDE) investigating local adaptation in common milkweed (Asclepias syriaca), a host plant for the monarch butterfly population. Faculty participants were recruited from the Ecological Research as Education Network (EREN) who recruited their former undergraduate students. Quantitative data were drawn from the Milkweed Local Adaptation (MLA) CDE database across the three project years. Qualitative data included faculty survey responses, semi‐structured interviews of faculty and former undergraduates, and review of undergraduate research posters, papers, and curricula using rubrics aligned with 4DEE and Next Generation Science Standards (NGSS) benchmarks. Analysis of the MLA CDE database illustrates a decline in both participating institutions and in counts of milkweed stems over the project (2018–2020). Qualitative data analysis revealed that CDEs: (1) offer opportunities for higher education faculty and their students to be part of research including developing skills of data collection, analysis, and interpretation; (2) have unexpected challenges; and (3) can inspire undergraduate students to develop independent research projects or curricular modules for use in formal 6–12 classrooms. Broader ecological educational implications of our outcomes for higher education faculty and their undergraduate students include: (1) recommendation that faculty members involved ought to be proactively informed about potential challenges and provided with guidance on how to mitigate them; (2) mitigating challenges with model studies to try to estimate the sample size and redundancy likely to produce robust data; and (3) proactive use of the educational network to understand institutional use of the CDE project with undergraduates.

Persistent knee pain following unicompartmental knee arthroplasty despite no identified cause and proactive patient use of standard and alternative therapies

Persistent knee pain following unicompartmental knee arthroplasty despite no identified cause and proactive patient use of standard and alternative therapies

Proactive assessment of patient reported outcomes in patients with ovarian cancer.

5567 Background: Patient reported outcome (PRO) measures are key instruments to provide an evaluation of health outcomes from the patient's perspective. Assessment of PROs may help identify the nature, severity, and time course of symptoms of concern in patients with ovarian cancer. The ability to access this information in real-time, including changes over time, could improve patient safety and decision-making. Methods: This systematic review evaluated the proactive or real-time assessment of PROs in patients with ovarian cancer undergoing systemic therapy. Medline, Embase, and Cochrane databases were searched (up to February 2022), and prospective ovarian cancer studies (experimental or observational) that incorporated PROs (including quality of life) were included. Conference abstracts were excluded. Primary objective was to assess the frequency of studies incorporating proactive use of PROs. A secondary objective was to describe PRO reporting. Descriptive statistics were used. Results: 3,071 articles were screened, with 117 included in the final analysis. Studies were published between 1990-2022 and contained 35,735 patients (median 140 patients per study; inter-quartile range 58-415). Median time from patient enrollment initiation to study publication was 7 years (range 1-15). Most studies were experimental/clinical trials (n=93, 79%), followed by observational (n=23, 20%) and not reported (n=1; Table). Among experimental studies, 56% (52/93) were phase III, 35.5% (33/93) phase II, 6.5% (6/93) phase I or I/II trials and it was not reported in two. Therapeutic strategies were assessed in 98% (91/93) of experimental studies, being the most frequent one chemotherapy (n=53, 58%), followed by antiangiogenics and PARP inhibitors (n=8, 9%, each). Types of observational studies were descriptive 43.5% (10/23), cohort 26% (6/23), cross-sectional 22% (5/23), or other 9% (2/23). PROs were the primary objective in 7.5% (7/93) and 83% (19/23) of experimental and observational studies respectively. The table describes PRO reporting standards per type of study. PROs were assessed in real-time in 0.8% (1/117) of studies. Conclusions: Completion of PRO and quality of life questionnaires involve time and effort for patients with ovarian cancer. PRO questionnaire responses were only assessed in real-time in <1% of analyzed studies. Efforts should be made to incorporate proactive assessment of PROs to optimize patient care and safety. [Table: see text]

PCR144 Evaluation of the Association between Self-Perceptions of Aging and Care Deferrals Among US Adults Aged ≥50 Years during the COVID-19 Pandemic

Self-perceptions of aging (SPA) have been shown to influence healthcare-seeking behaviors among middle-aged and older adults. Negative SPA may intensify the COVID-19 pandemic-related healthcare disruptions in this population. Therefore, this study seeks to evaluate the association between SPA and care deferrals among community-dwelling adults aged ≥50 years in the US during the COVID-19 pandemic. A cross-sectional study of the eligible sample was conducted using data from the 2020 wave of the Health and Retirement Study. SPA score was measured using a validated eight-item instrument with higher scores indicating negative SPA. The association between SPA and care deferrals during the COVID-19 pandemic was assessed using multivariable logistic regression adjusted for respondents’ sociodemographic and clinical characteristics, past COVID-19-related experiences, and COVID-19 worry. The final sample consisted of 4,153 community-dwelling adults aged ≥50 years. 30% reported care deferrals during the COVID-19 pandemic. Among respondents who deferred care, the majority were aged 50-64 years (46.6%), females (65.4%), and White (64.5%). Most commonly reported care deferrals were dental appointments (74.5%) and physician visits (56.5%). Care deferrals were mainly due to clinic/office rescheduling or cancelling appointments (57.5%), respondent deciding the care could wait (33.8%), and COVID-19 fear (21.8%). Respondents reporting care deferrals reported higher mean SPA scores, indicating negative aging attitudes, compared those who did not defer care (Mean (SD): 3.24 (1.02) vs. 3.05 (1.04), p<0.001). After accounting for covariates, higher SPA scores were associated with significantly higher odds of care deferrals (aOR: 1.20, 95% CI: 1.11 – 1.30, p<0.001). This study found that negative SPA were associated with care deferrals during the COVID-19 pandemic among community-dwelling adults aged ≥50 years. As healthcare delivery rebounds to pre-pandemic levels, the role of SPA in healthcare-seeking behaviors should be recognized. Health promotion efforts may target positive aging attitudes to encourage timely and proactive use of healthcare.

Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.

Profiles of teacher’s professional agency in the classroom across time

ABSTRACT Teachers with strong professional agency (TPA) in the classroom make efforts to constantly learn and develop their teaching practices. The aim of the present study is to identify teachers’ different TPA development profiles and their association with experiencing burnout symptoms and abilities to use proactive strategies in regulating well-being. A total of 1920 Finnish primary school teachers responded during the two-year follow-up study. The data were analysed using longitudinal latent profile analysis. Four profiles were found: (1) High and stable professional agency; (2) Moderately high professional agency; (3) Increasing professional agency; and (4) Decreasing professional agency. Most teachers experienced strong and stable professional agency and only few changes in their sense of professional agency over time. Socio-contextual burnout symptoms and proactive strategy use differentiated the profiles well. Teachers with lower professional agency profiles experienced more burnout symptoms and less ability to use proactive strategies.

Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children's experience.

Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them. Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children's between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded. Median age at index procedure was 23 years (range 0.25-48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation. Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.

Offloading devices for the prevention of heel pressure ulcers: A realist evaluation

BackgroundHeel pressure ulcers can cause pain, reduce mobility, lead to longer hospital stays and in severe cases can lead to sepsis, amputation, and death. Offloading boots are marketed as heel pressure ulcer prevention devices, working by removing pressure to the heel, yet there is little good quality evidence about their clinical effectiveness. Given that evidence is not guiding use of these devices, this study aims to explore, how, when, and why these devices are used in hospital settings. ObjectiveTo explore how offloading devices are used to prevent heel pressure ulcers, for whom and in what circumstances. MethodsA realist evaluation was undertaken to explore the contexts, mechanisms, and outcomes that might influence how offloading devices are implemented and used in clinical practice for the prevention of heel pressure ulcers in hospitals. Eight Tissue Viability Nurse Specialists from across the UK (England, Wales, and Northern Ireland) were interviewed. Questions sought to elicit whether, and in what ways, initial theories about the use of heel pressure ulcers fitted with interviewee's experiences. ResultsThirteen initial theories were refined into three programme theories about how offloading devices are used by nurses ‘proactively’ to prevent heel pressure ulcers, ‘reactively’ to treat and minimise deterioration of early-stage pressure ulcers, and patient factors that influence how these devices are used. ConclusionsOffloading devices were used in clinical practice by all the interviewees. It was viewed that they were not suitable to be used by every patient, at every point in their inpatient journey, nor was it financially viable. However, the interviewees thought that identifying suitable ‘at risk’ patient groups that can maintain use of the devices could lead to proactive and cost-effective use of the devices.This understanding of the contexts and mechanisms that influence the effective use of offloading devices has implications for clinical practice and design of clinical trials of offloading devices. Tweetable abstractHow, for whom, and in what circumstances do offloading devices work to prevent heel pressure ulcers? Tissue viability nurses' perspectives.

The importance of early and proactive use of long-acting injectable antipsychotics in the management of schizophrenia.

Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan Received 9 January 2023 Accepted 6 February 2023. Correspondence to Hiroyoshi Takeuchi, MD, PhD, Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan, Tel: +81 3 3353 1211; fax: +81 3 5379 0187; e-mail: [email protected]

Early versus late administration of long-acting injectable antipsychotic agents among patients with newly diagnosed schizophrenia: an analysis of a commercial claims database.

This study was designed to assess healthcare resource utilization (HCRU) and costs in patients with newly diagnosed schizophrenia based on timing and context of long-acting injectable antipsychotic agent (LAI) initiation. Using claims data, patients (aged 18-40 years) with first schizophrenia diagnosis January 2013-September 2019 (index date), no LAI or oral antipsychotic agent claims during 12-month preindex period, and continuous benefit enrollment from 12 months before index date to 12 months after first LAI administration were identified. Patients were grouped based on timing [early (≤1 year after index date) vs. late] and circumstances [reactive (after schizophrenia-related event) vs. proactive] of LAI initiation. Of 1290 patients with at least one LAI claim, 306 met criteria for early ( n = 204; reactive, n = 107; proactive, n = 97) and late ( n = 102; n = 75; n = 27) initiation. HCRU and costs were numerically lower in early versus late groups, and significantly lower for proactive initiation in both groups. Comparing worst-case (late-reactive) and best-case (early-proactive) scenarios, the average annual cost difference was $7195.13 ( P = 0.0233), with major drivers being emergency department ($171.28; P < 0.05) and other outpatient ($2845.73; P < 0.00001) visits. In addition to the clinical advantages previously described in the literature, the proactive use of LAIs in early-phase schizophrenia is associated with lower healthcare costs.

Accountability in artificial intelligence: what it is and how it works

AbstractAccountability is a cornerstone of the governance of artificial intelligence (AI). However, it is often defined too imprecisely because its multifaceted nature and the sociotechnical structure of AI systems imply a variety of values, practices, and measures to which accountability in AI can refer. We address this lack of clarity by defining accountability in terms of answerability, identifying three conditions of possibility (authority recognition, interrogation, and limitation of power), and an architecture of seven features (context, range, agent, forum, standards, process, and implications). We analyze this architecture through four accountability goals (compliance, report, oversight, and enforcement). We argue that these goals are often complementary and that policy-makers emphasize or prioritize some over others depending on the proactive or reactive use of accountability and the missions of AI governance.

Thirty years of hemovigilance - achievements and future perspectives.

Since its emergence in the early 1990s, hemovigilance has gradually evolved from a blood safety concept focused on surveillance of adverse reactions and events in patients, to a well-defined system that monitors the entire transfusion chain and improves its safety. The importance of hemovigilance has been recognized globally in a relatively short time, but the level of its implementation varies significantly between countries. The cooperation of international organizations has significantly contributed to the promotion, implementation, and education in this field. Thanks to initiatives taken, the safety of transfusion practice has been improved in many segments, primarily related to the risks of adverse events in recipients of blood components. In parallel with changing transfusion practice, the hemovigilance process has also matured. In addition to the reduction of existing risks and the early detection of emerging risks, hemovigilance has also embraced the principles of patient blood management. Research in hemovigilance is more increasingly focused on specific categories of patients, specific blood components and methods of their preparation, rare reactions, and transfusion efficacy and efficiency. A proactive approach and use of big data can play an important role in achieving these goals. Additional and sustained efforts should be made to prevent underreporting of events and to improve data comparability through clear definitions and grading systems. This review provides a historical overview of hemovigilance and its achievements, current challenges, and future plans.

Proactive use of QI methodology in consultation-liaison psychiatry to support the opening of a new COVID+ behavioral health inpatient unit during the omicron surge

Inpatient consultation-liaison (CL) psychiatry teams routinely facilitate the transfer of medically stable patients in behavioral health crisis from the general hospital to inpatient psychiatric units. The COVID-19 pandemic had a significant impact on this process when inpatient psychiatric units were unable to provide care for patients with asymptomatic COVID-19 infection because of infection control concerns in units unable to accommodate isolation precautions. Similar to other disrupted hospital workflows, these clinical handoffs became more complicated by requiring COVID exposed or COVID+ patients in the midst of behavioral health crisis to quarantine or isolate on general hospital units if not otherwise stable for discharge to the community. To better respond to the growing number of patients isolating in the general hospital during the 2022 Omicron surge, we used quality improvement (QI) methodology to illustrate the need to create a COVID+ unit in the inpatient psychiatric hospital to care for the growing cohort of COVID+ patients in psychiatric crisis who were otherwise unable to access traditional psychiatric hospital care because of their isolation status.