Routine Visits Research Articles

Association of HbA1C and comfort with diabetes self-management among adolescents and young adults with type 1 diabetes

IntroductionAdolescents and young adults (AYA) living with type 1 diabetes (T1D) are a vulnerable demographic at risk for sub-optimal glycemic outcomes at a time when they are taking over their diabetes management. The purposes of this study were to examine levels of self-reported comfort with diabetes management tasks among AYA living with T1D and to describe the relationships among comfort levels, sociodemographic factors, and HbA1c. MethodsDuring a routine diabetes care visit, AYA aged 15–23 years old living with T1D received a transition survey to self-assess their comfort level with different diabetesmanagement tasks. ResultsAmong 161 participants who completed the survey (median age 17 years, median diabetes duration 7 years, 82.3% White, 40.9% female, 66.5% with private insurance, and median HbA1c 8.8%), comfort with diabetes management tasks was generally rated highly (median overall comfort level of 4.5 out of 5), irrespective of race or insurance type. Regression analysis revealed that higher self-reported comfort level with diabetes management tasks was associated with a higher HbA1c (p = 0.006), after controlling for age, sex, race, insurance type, and diabetes duration. DiscussionThese findings suggest that self-reported comfort with independently managing T1D may not be a sufficient metric in assessing AYA patients’ need for further intervention to optimize glycemic outcomes as they transition from pediatric to adult diabetes care, and highlights the importance of continuity of care to support diabetes management during this transitional period.

Aminotransferase trends in propionic acidemia

AbstractPropionic acidemia is a metabolic condition with multiple serious acute and chronic presentations that require strict monitoring. Literature on liver function abnormalities in propionic acidemia is scarce, and the mechanism of liver impairment in this condition remains unclear. Currently, there is no indication for liver‐function tests during follow‐up and their clinical or prognostic utility is unknown. This study aimed to determine aminotransferase trends in individuals with propionic acidemia at a single institution. We retrospectively evaluated and classified the aminotransferases of 12 patients with propionic acidemia during hospital admissions and routine office visits. The present findings suggest that aminotransferase elevations are very common in this population and can persist beyond acute illness. During hospitalization events, aminotransferases were not a predictor of severity, duration of stay, and readmission within 1 month. Understanding aminotransferase trends in these patients will help clinicians make decisions in the acute setting and potentially in the follow‐up of new therapies.

Maternal vascular indices at 36 weeks' gestation in small and growth restricted fetuses.

To compare maternal vascular indices and hemodynamic parameters at 35-37 weeks' gestation, in pregnancies complicated by small for gestational age (SGA) fetuses and those with fetal growth restriction (FGR). This was a prospective observational non-intervention study in women with singleton pregnancies attending for a routine hospital visit at 35+0 to 36+6 weeks' gestation. The visit included recording of maternal demographic characteristics and medical history, vascular indices and hemodynamic parameters obtained by a non-invasive operator independent device, including pulse wave velocity, augmention index, cardiac output, stroke volume, central systolic and diastolic blood pressure, total peripheral resistance and fetal heart rate. Hypertensive disorders of pregnancy were excluded and the values in the SGA and FGR groups were compared between them and with unaffected pregnancies. Diagnosis of SGA was based on the birth of a baby with birthweight below the 10th percentile for gestational age. In FGR, in addition to a birthweight below the 10th percentile, at the 35-37 weeks scan Doppler studies had shown that the uterine artery or umbilical artery pulsatility index (PI) was above the 95th percentile for gestational age or the fetal middle cerebral artery PI was below the 5th percentile. In the 6,413 women included in the study there were 605 (9.4%) cases of SGA, 133 (2.1%) of FGR and 5,675 (88.5%) unaffected by SGA or FGR. Women with SGA or FGR, compared to unaffected pregnancies, had increased peripheral vascular resistance and reduced cardiac output. Central systolic and diastolic blood pressure were also increased, whereas aortic stiffness assessed by pulse wave velocity and augmentation index did not differ between affected and unaffected pregnancies. In the FGR, compared to the SGA group, central systolic and diastolic blood pressure were higher, whereas, heart rate was lower. In SGA and FGR pregnancies there are deranged maternal hemodynamic responses when these are compared to normal pregnancies. Mothers with FGR babies have higher central blood pressure compared to SGA ones, but it remains unclear whether these differences are driven by the size of the fetus or pathological fetal growth. This article is protected by copyright. All rights reserved.

Conversion of a Validated Melanoma Risk Stratification Tool Into a Tablet-Based Patient Questionnaire for Targeted Melanoma Screening in Primary Care Settings: A Pilot Study.

Risk stratification can identify individuals in primary care settings who are at increased risk of developing melanoma. Converting and implementing a validated risk stratification tool as a patient self-administered tablet-based survey. Mackie risk stratification tool was transformed into a patient questionnaire. The questionnaire was completed in academic dermatologist practices by patients and dermatologists and revised to optimize sensitivity and specificity using physician assessment as gold standard. The optimized survey was administered before routine primary care visits during 2019 to 2021. High-risk patients were referred to dermatology. The number needed to screen (NNS), sensitivity, specificity, positive predictive value, and negative predictive value to identify a melanoma were calculated. Of the 7,893 respondents, 5,842 (74%) and 2,051 (26%) patients were categorized as low-risk and high-risk population, respectively. The NNS to identify 1 melanoma was 64 in the high-risk population. Incorporating self-administered patient-risk stratification tools in primary care settings can identify high-risk individuals for targeted melanoma screening. Further studies are needed to optimize specificity and sensitivity in more targeted populations.

Erectile Dysfunction and Depression Prevalence Among Male Patients with Type II Diabetes.

Patients with Type 2 Diabetes (T2D) are at substantial risk for developing erectile dysfunction (ED). The primary goal of this study was to assess the prevalence of ED and depression among T2D patients and the associated risk factors. A cross-sectional study was conducted for adult T2D patients who had a routine clinic visit between January-August 2023. Structured questionnaires formed with two validated questionnaires - the International Index of Erectile Function short form (IIEF-5) and Patient Health Questionnaire (PHQ-9) - were used to screen for ED and depression, respectively. A total of 478 male patients with T2D with a mean age of 59.2 ± 10.8 years, mostly married, with long standing T2D were included. Hyperlipidemia followed by hypertension were the most reported comorbidities. Of the patients, 61.3% had reported no depression and were less likely to have ED or severe ED (p <0.001) and more likely to be physically active and to report no smoking (p <0.0001) when compared to those with depression. Fifty-two percent of the patients reported moderate and severe ED and those were older in age (p = 0.031), had longer duration of T2D diagnosis (p = 0.005), were more likely to have any comorbidities (p <0.05), were less likely to have a university degree and higher income (both p <0.001), were less likely to be on oral hypoglycemic agents (OHA) (p <0.001), had worse glycemic control parameters (p = 0.463), were more likely to have positive urine microalbuminuria (p = 0.019), and were less likely to be physically active (p = 0.048) when compared to patients with no or milder degree of ED. ED is highly prevalent in our study sample, with half of the patients having moderate to severe ED and being more likely to have depression. Older age, long-standing T2D, comorbidities, socioeconomic disadvantage, and sedentary lifestyle were all significantly associated with ED.

Integration of the expanded disability status scale with ambulation, visual and cognitive tests.

The Expanded Disability Status Scale (EDSS) is usually calculated through a neurological examination with self-reported performance. This may lead to incorrect assessment of Functional System scores (FSs). Aim of our study was to estimate the difference between EDSS obtained during routine visits, or after specific tests. We enrolled 670 MS patients that underwent a regular neurology consultation, and visual evaluation using optotype tables, ambulation evaluation with a rodometer, and cognitive assessment with the Brief International Cognitive assessment for MS (BICAMS). We calculated a new integrated EDSS (iEDSS) using the refined values of the FS and compared it to the standard EDSS. Visual, cerebral and ambulation FSs were significantly higher compared with the self-reported counterpart [+ 1.169 (95%CI 1.077, 1.262; p < 0.001), + 0.727 (95%CI 0.653, 0.801; p < 0.001) and + 0.822 (95%CI 0.705, 0.939; p < 0.001), respectively]. Mean iEDSS was higher than EDSS (+ 0.642; p < 0.001). Visual acuity tests worsened the EDSS in 31% of cases, cognitive tests in 10%, ambulation measurement in 35%, all three measurements in 59% of cases. Objective measurement of FSs results in a more accurate EDSS score in almost two-thirds of cases. This could lead to a more thorough evaluation of patients in the transition or progressive phase.

Physician estimate of inflammation vs global assessment in explaining variations in swollen joint counts in rheumatoid arthritis patients

Abstract Objective To analyze patients with rheumatoid arthritis (RA) for inflammatory activity by physician estimate of global assessment (DOCGL) vs an estimate of inflammatory activity (DOCINF) to explain variation in swollen joint count (SJC). Methods Patients with RA were studied at routine care visits. Patients completed a multidimensional health assessment questionnaire (MDHAQ), and the physician completed a 28-joint count for swollen (SJC), tender (TJC) and deformed (DJC) joints, and a RheuMetric checklist with a 0–10 DOCGL visual numeric scale (VNS), and 0–10 VNS estimates of inflammation (DOCINF), damage (DOCDAM) and patient distress (DOCSTR). Disease activity score 28 (DAS28-ESR), clinical disease activity index (CDAI) and routine assessment of patient index data (RAPID3) were calculated. Individual scores and RA indices were compared according to Spearman correlation coefficients and regression analyses. Results 104 unselected patients were included, with median age and disease duration of 55.0 and 5 years respectively. Median (IQR) DAS28-ESR was 2.89 (1.64), indicating low activity. DOCINF was correlated significantly with DOCGL (rho= 0.775). Both DOCGL and DOCINF were correlated significantly with most other measures; correlations with DOCGL generally were higher than with DOCINF other than for SJC. In regression analyses, DOCINF was more explanatory of variation in SJC than DOCGL and other DAS28-ESR components. Conclusions Variation in SJC is explained more by a 0–10 DOCINF VNS than the traditional DOCGL or any other measure in routine care RA patients. DOCINF on a RheuMetric checklist can provide informative quantitative scores concerning inflammatory activity in RA patients monitored over long periods.

Prevalence of depression among older people in Iraq

Background: The global prevalence of mental disorders, including depression, has steadily increased. Objective: To identifying the prevalence rate of depression and the related predictors among old-age people in Iraq. Patients and Methods: A cross-sectional study was conducted from August to November 2021. A random sampling technique was employed to gather information from the old age patients during their routine visits to outpatient clinic of three public hospitals (Baquba, Ramadi, Samarra), in Iraq. Data collection involved the utilization of a semi-structured questionnaire incorporating the validated Geriatric Depression Scale (GDS-30) administered through face-to-face interviews. Descriptive, bivariate, and multivariate logistic regression analyses were employed to examine the relationships between variables in the study. SPSS version 16 was utilized for data analysis, with statistical significance set at a threshold below 0.05. Results: Data of 344 old-age respondents (range 60-81 years) with a mean age of 75.15 (± 7.52) years have undergone final analysis. More than half were males (50.6%), married (62.2%), ranked themselves as unhealthy (72.4%), physically inactive (70.6%), and financially dependent (71.8%). The overall prevalence of depression was 74.4%. Logistic regression revealed significant associations: elderly females had 3.805 times higher risk (P&lt;0.001,95% CI: 1.999 to 5.241), unhealthy individuals had 2.379 times (P&lt;0.001, 95% CI 1.657 to 3.415), limited activities of daily living (ADL) had 2.650 times (P =0.001, 95% CI: 1.076 to 3.902), and those lacking family support had1.799 times (P = 0.003, 95% CI: 1.040 to 3.746) than their counterparts. Conclusion: High depression rates and multiple risk factors necessitate the urgent need for health and political intervention to support patients and promote greater social participation. Keywords: Depression, Old Age, ADL, Prevalence, Risk Factors, Logistic Regression, Iraq

Prevalence of depression among older people in Iraq

Background: The global prevalence of mental disorders, including depression, has steadily increased. Objective: To identifying the prevalence rate of depression and the related predictors among old-age people in Iraq. Patients and Methods: A cross-sectional study was conducted from August to November 2021. A random sampling technique was employed to gather information from the old age patients during their routine visits to outpatient clinic of three public hospitals (Baquba, Ramadi, Samarra), in Iraq. Data collection involved the utilization of a semi-structured questionnaire incorporating the validated Geriatric Depression Scale (GDS-30) administered through face-to-face interviews. Descriptive, bivariate, and multivariate logistic regression analyses were employed to examine the relationships between variables in the study. SPSS version 16 was utilized for data analysis, with statistical significance set at a threshold below 0.05. Results: Data of 344 old-age respondents (range 60-81 years) with a mean age of 75.15 (± 7.52) years have undergone final analysis. More than half were males (50.6%), married (62.2%), ranked themselves as unhealthy (72.4%), physically inactive (70.6%), and financially dependent (71.8%). The overall prevalence of depression was 74.4%. Logistic regression revealed significant associations: elderly females had 3.805 times higher risk (P&lt;0.001,95% CI: 1.999 to 5.241), unhealthy individuals had 2.379 times (P&lt;0.001, 95% CI 1.657 to 3.415), limited activities of daily living (ADL) had 2.650 times (P =0.001, 95% CI: 1.076 to 3.902), and those lacking family support had1.799 times (P = 0.003, 95% CI: 1.040 to 3.746) than their counterparts.  Conclusion: High depression rates and multiple risk factors necessitate the urgent need for health and political intervention to support patients and promote greater social participation.

P050 Determining the feasibility of a multi-centre randomised clinical trial to test the effectiveness of integrated symptom tracking for managing rheumatoid arthritis

Abstract Background/Aims In a series of studies, we co-developed and piloted the remote monitoring of rheumatoid arthritis (REMORA) system. REMORA enables patients to daily track symptoms via their smartphone and integrates this data into their electronic health record for discussion during routine clinic visits. This offers the opportunity to make better, and shared, treatment decisions and improve disease management. The effectiveness of integrated daily symptom tracking on clinical and patient-reported outcomes will be tested in a multi-centre stepped wedge randomised clinical trial (RCT). Here, we present the results of the REMORA feasibility study to test trial procedures and intervention delivery. Methods Across two NHS sites in the Northwest of England we aimed to recruit 60 patients, aged ≥18 years with rheumatoid arthritis (RA) or inflammatory arthritis (IA), and access to an Android/iOS smartphone with daily internet access. Participants were asked to complete a baseline web-survey and use the REMORA app to collect daily symptom reports for up to six months. Clinical care teams extracted data from participants’ medical records for all baseline and follow-up appointments, including disease activity scores. To assess feasibility, we reported recruitment rates, participants’ uptake of and adherence to daily symptom tracking, and outcome data completeness. We also compared characteristics of a) those who consented vs. trackers (defined as submitting ≥1 symptom report, i.e., successful intervention uptake), and b) high adherers (symptoms reported on &amp;gt; 60% days) vs. low adherers (symptoms reported on &amp;lt; 25% days). Results A total of 130 patients were screened across study sites, and 52 were eligible and provided consent to take part (40.0%). Of those, 32 (61.5%) initiated symptom tracking; their demographic characteristics were broadly similar to those who consented, though more people of white ethnicity appeared higher in the tracker group (93.8% (95% CI 79.2-99.2) vs 86.5% (74.2-94.4), respectively). Participants completed at least one symptom report on 63.2% of study days (2384/3771 days). We observed few differences between low vs high adherers, though low adherers (n = 6) were younger (median (IQR) years: 41.5 (34.5-55.3)) than the high engagers (n = 20; 61.0 (50.5-65.3)) and had a shorter disease duration (years: 1.0 (0-5.8) vs 3.0 (0.8-10.8)). In total, 48 consented participants had at least one follow-up appointment during the study window; 46 (95.8%) had complete primary outcome data. Conclusion Across two clinical sites, we determined that the procedures and intervention delivery designed for use within a future multi-centre stepped wedge RCT of the REMORA system were feasible for recruitment, adherence to the intervention and completion of the primary outcome. However, uptake of the intervention was lower than we hoped. To enhance intervention uptake in the main trial, we clarified inclusion criteria, improved patient information on what is required to initiate symptom tracking and modified our supporting materials. Disclosure K.L. Druce: None. M. Parkes: None. R. Bravo: None. D. Griffiths-Jones: None. S.N. van der Veer: None. W. Dixon: Consultancies; consultancy fees from Google unrelated to this work. J. McBeth: None.

Prevalence, Epidemiological, and Clinical Profile of Patients Coinfected with Human Immunodeficiency Virus and Tuberculosis in the Coronavirus Disease 2019 Context in Health Facilities in the East Region, Cameroon

Background and Objective Suspected cases of tuberculosis (TB) are identified for confirmation by bacteriological tests through clinical screening for TB in people living with human immunodeficiency virus (HIV) during routine visits or when antiretrovirals (ARVs) are dispensed. Our aim is to determine the prevalence and describe the epidemiological and clinical characteristics of HIV-TB coinfected patients in the coronavirus disease 2019 (COVID-19) setting in health facilities in the East Region of Cameroon. This study addresses knowledge gaps on HIV-TB coinfection during COVID-19, aiming to provide insights into the interaction and impact of HIV, TB, and COVID-19 on individuals’ health. Methods This was an observational study. It involved two retrospective cohorts of HIV-TB coinfected patients before and after the COVID-19 pandemic. We conducted manual reviews of the medical records and antiretroviral therapy (ART) and TB registers of 262 patients. These patients were coinfected with HIV and TB during the period from April 2019 to April 2021 in 11 health facilities in the East Cameroon health region. The sociodemographic and clinical characteristics of the cases were extracted from the consultation registers and entered into the KoBo Collect application, then analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 25. Results In this study of 262 HIV-TB coinfection cases, 60.3% occurred before COVID-19, and 39.7% during the pandemic. HIV-TB coinfection prevalence among HIV patients was 1%. Patients averaged 39.3 years in age, with a significant shift in sex ratios from 0.65 to 1.33 between pre-COVID-19 and COVID-19 cohorts. Education varied, with 45.8% having secondary education, 44.8% with primary, 2.4% having higher education, and 7.1% having none. Most (78.9%) had professional occupations, and 53.7% lived in rural areas. The majority were newly diagnosed (96.3% before COVID-19; 93.3% during COVID-19), with 3.7% relapses and 4.2% discontinuing treatment. Most had pulmonary TB (84.9%) and were aware of treatment duration (94.6%). About 65.4% experienced treatment-related adverse events. Regarding family support, 69.3% received help with medication. However, the concern was 80.6% did not adhere to anti-COVID-19 measures. Conclusion and Global Health Implications Gender was significantly associated with compliance. Most patients were on treatment, but a small percentage had discontinued it. Patients need to be made aware of the importance of complying with anti-COVID-19 barrier measures to prevent a potential worsening of the health situation. Moreover, clinical and biological monitoring needs to be stepped up throughout the course of anti-TB treatment.

Risk perception, well-being, depression and anxiety in children and adolescents with rheumatic diseases during the COVID-19 pandemic - results from the prospective multicenter KICK-COVID study in Germany

ObjectiveTo investigate the psychosocial burden in children and adolescents with juvenile rheumatic diseases during the COVID-19 pandemic.MethodsAs part of the multicentre observational KICK-COVID study linked to the National Pediatric Rheumatology Database, adolescents < 21 years and parents of children < 12 years with rheumatic diseases answered questions on perceptions of health risk (PHR) due to SARS-CoV2, stress, well-being (WHO-5) and symptoms of depression (PHQ-9) and anxiety (GAD-7). Data were collected at routine visits from June to December 2021 and assessed for association with demographic and clinical parameters, treatment and patient-reported outcomes by multivariable regression analyses.ResultsData from 1356 individuals (69% female, 50% adolescents) were included. Median PHR on a numeric rating scale (NRS, 0–10) was 4 (IQR 2–6), median perceived stress was 3 (IQR 1–6). Adolescents reported a worse well-being with a significantly lower median WHO-5-score (60, IQR 40–76) than parents reported for their children < 12 years (80, IQR 68–84). Moderate to severe symptoms of depression and anxiety were reported by 14.3% and 12.3% of the adolescents, respectively. PHR was significantly higher in patients with systemic lupus erythematosus, methotrexate or biologic disease-modifying anti-rheumatic drug therapy than in patients without these characteristics, whereas lower WHO-5 or higher PHQ-9 or GAD-7 scores were only associated with poorer patient-reported health status and physical functioning.ConclusionThe perception of health risk due to SARS-CoV2 infection was not paralleled by an impairment of mental health, which were, however, significantly correlated with self-rated health status and functional capacity, highlighting the importance of patient-reported outcome assessment.Trial registrationGerman Clinical Trials Register (DRKS), no. DRKS00027974. Registered on 27th of January 2022.

Child behaviour is a main concern for parents of 3-year-olds.

The aim of this study was to describe parental concerns about child health and behaviour and their sociodemographic predictors in 3-year-olds, in relation to the national guidelines of well-baby clinics. The study included parents of 33 526 children in Stockholm who had completed a questionnaire prior to a routine visit to a well-baby clinic at age 3 years. Multivariate regression was used to analyse predictors for concerns. Child behaviour problems, defined as defiance and problem with adherence to daily routines, were the most common parental concerns (36.4%), with poor social skills and relations being second (21.8%). Regarding development, 9.6% had concerns about speech and 4.7% about motor development. Screen use (9.5%) and being underweight (6.3%) were other common parental concerns, while lifestyle concerns regarding physical activity and overweight were rare. Parents raised about twice as many concerns for first-born children compared with younger siblings. Child behaviour and developmental concerns were more frequent in families where the mother had primary education only and attended a well-baby clinic with a high Care Need Index. Parents' concerns reflected the national guidelines about child development and behaviour, but not its emphasis on a healthy lifestyle.

Hepatitis C screening in Lithuania: first-year results and scenarios for achieving WHO elimination targets.

The World Health Organization (WHO) has outlined a set of targets to achieve eliminating hepatitis C by 2030. In May 2022, Lithuanian health authorities initiated a hepatitis C virus (HCV) screening program to start working towards elimination. In the program, bonus was given to general practitioners (GPs) to promote and conduct anti-HCV tests for two situations: (1) one time testing for individuals born in 1945-1994 and (2) annual HCV testing for persons who inject drugs or are living with human immunodeficiency virus (HIV) regardless of age. This study aimed to model the current viral hepatitis C epidemiological status in Lithuania and to outline the requirements for WHO elimination targets using the first-year HCV screening results. Individuals were invited to participate in the anti-HCV screening by GPs during routine visits. Patients who tested positive were then referred to a gastroenterologist or infectious disease doctor for further confirmatory testing. If a patient received a positive RNA test and a fibrosis staging result of ≥ F2, the doctor prescribed direct-acting antivirals. Information on the patients screened, diagnosed, and treated was obtained from the National Health Insurance Fund. The Markov disease progression model, developed by the CDA Foundation, was used to evaluate the screening program results and HCV elimination progress in Lithuania. Between May 2022 and April 2023, 790,070 individuals underwent anti-HCV testing, with 11,943 individuals (1.5%) receiving positive results. Anti-HCV seroprevalence was found to be higher among males than females, 1.9% and 1.2%, respectively. Within the risk population tested, 2087 (31.1%) seropositive individuals were identified. When comparing the screening program results to WHO elimination targets through modelling, 2180 patients still need to be treated annually until 2030, along with expanding fibrosis restrictions. If an elimination approach was implemented, 1000 new infections would be prevented, while saving 150 lives and averting 90 decompensated cirrhosis cases and 110 hepatocellular carcinoma cases. During the first year of the Lithuanian screening program, GPs were able to screen 44% of the target population. However, the country will not meet elimination targets as it currently stands without increasing treatment levels and lifting fibrosis restrictions.

Routine 6-Week Outpatient Radiography and Visit in Patients with Conservatively Treated Multiple Rib Fractures: Valuable or a Waste of Resources?

This study investigated the incidence and clinical consequences of abnormal radiological and clinical findings during routinely performed 6-week outpatient visits in patients treated conservatively for multiple (3 or more) rib fractures. A retrospective analysis was conducted among patients with multiple rib fractures treated conservatively between 2018 and 2021 (Opvent database). The primary outcome was the incidence of abnormalities on chest X-ray (CXR) and their clinical consequences, which were categorized as requiring intervention or additional clinical/radiological examination. The secondary focus was the incidence of deviation from standard treatment in response to the findings (clinical or radiological) at the routine 6-week outpatient visit. In total, 364 patients were included, of whom 246 had a 6-week visit with CXR. The median age was 57 years (interquartile range, 46-70 years) and the median Injury Severity Score was 17 (interquartile range, 13-22). Forty-six abnormalities (18.7%) were found on CXR. These abnormalities resulted in additional outpatient visits in 4 patients (1.5%) and in chest drain insertion in 2 (0.8%). Only 2 patients (0.8%) with an abnormality on CXR presented without symptoms. None of the 118 patients who had visits without CXR experienced problems. Routine 6-week outpatient visits for patients with conservatively treated multiple rib fractures infrequently revealed abnormalities requiring treatment modifications. It may be questioned whether the 6-week outpatient visit is even necessary. Instead, a more targeted approach could be adopted, providing follow-up to high-risk or high-demand patients only, or offering guidance on recognizing warning signs and providing aftercare through a smartphone application.

Predictors of Breastfeeding among Women Admitted with Severe Preeclampsia Before 34 Weeks.

Patients with severe preeclampsia (sPREX) face barriers to successful breastfeeding (BF), including an increased risk of maternal and newborn complications, prematurity, and low birth weight. Patients with early-onset sPREX (before 34 weeks' gestation) may be at even greater risk, yet there are little data available on factors associated with BF challenges in this population. We describe rates of BF initiation at hospital discharge and BF continuation at postpartum (PP) visit and identify factors associated with BF noninitiation and BF cessation among patients admitted with early-onset sPREX. Retrospective cohort study of women with sPREX admitted at less than 34 weeks' gestation to a single tertiary center (2013-2019). Demographic, antepartum, and delivery characteristics were evaluated. Factors associated with BF noninitiation at maternal discharge and with BF cessation at routine PP were assessed. Patients with intrauterine or neonatal demise and those missing BF data were excluded. Bivariate statistics were used to compare characteristics and Poisson regression was used to estimate relative risks (RR). Of 255 patients with early-onset sPREX, 228 (89.4%) had BF initiation at maternal hospital discharge. Initiation of BF occurred less frequently among patients with tobacco use in pregnancy (7.5 vs. 37.0%, χ2 p < 0.001, RR: 0.69 [95% confidence interval, CI: 0.52-0.92]). At 6 weeks' PP, 159 of 199 (79.9%) patients had BF continuation. Maternal age under 20 years (1.9 vs. 17.5%, χ2 p = 0.01, RR: 0.36 [95% CI: 0.14-0.91]) and experiencing maternal morbidity (25.2 vs. 45.0%, χ2 p = 0.01, RR: 0.80 [95% CI: 0.66-0.96]) were associated with BF cessation at the PP visit. Among patients with early sPREX, tobacco use in pregnancy was associated with noninitiation of BF at discharge, whereas young maternal age and maternal morbidity were associated with cessation of BF by routine PP visit. Further research is needed on how to support BF in this population, especially among patients with these associated factors. · Tobacco use was associated with BF noninitiation in patients with early preeclampsia.. · Maternal age < 20 and maternal morbidity were associated with BF cessation by PP visit.. · BF support for patients with risk factors is important for BF success PP..

Association of minor electrocardiographic (ECG) abnormalities with epilepsy duration in children: A manifestation of the epileptic heart?

PurposeCardiac abnormalities resulting from chronic epilepsy (“the epileptic heart”) constitute a well-recognized comorbidity. However, the association of cardiac alterations with epilepsy duration remains understudied. We sought to evaluate this association using electrocardiogram (ECG). MethodsWe prospectively enrolled children between 1 months and 18 years of age without known cardiac conditions or ion channelopathies during routine clinic visits. ECGs were categorized as abnormal if there were alterations in rhythm; PR, QRS, or corrected QT interval; QRS axis or morphology; ST segment or T wave. An independent association between ECG abnormalities and epilepsy duration was evaluated using multivariable logistic regression modeling. Results213 children were enrolled. 100 ECGs (47%) exhibited at least one alteration; most commonly in the ST segment (37, 17%) and T wave (29, 11%). Children with normal ECGs had shorter epilepsy duration as compared to those with ECG abnormalities (46 [18–91] months vs. 73 [32–128 months], p = 0.004). A multivariable logistic regression model demonstrated that increasing epilepsy duration was independently associated with the presence of ECG abnormalities (OR=1.09, 95% CI=1.02–1.16, p = 0.008), adjusted for seizure frequency, generalized tonic-clonic/focal to bilateral tonic-clonic seizures as the predominant seizure type, and number of channel-modifying anti-seizure medications. Increasing epilepsy duration was also independently associated with the presence of ST/T wave abnormalities (OR=1.09, 95% CI=1.01–1.16, p = 0.017), adjusted for the same covariates. SignificanceIncreasing epilepsy duration is independently associated with the presence of minor ECG abnormalities. Additional studies are needed to evaluate whether this finding may represent a manifestation of the “epileptic heart”.

Understanding the barriers to integrating maternal and mental health at primary health care in Vietnam.

The prevalence of common perinatal mental disorders in Vietnam ranges from 16.9% to 39.9%, and substantial treatment gaps have been identified at all levels. This paper explores constraints to the integration of maternal and mental health services at the primary healthcare level and the implications for the health system's responsiveness to the needs and expectations of pregnant women with mental health conditions in Vietnam. As part of the RESPONSE project, a three-phased realist evaluation study, we present Phase One findings which employed systematic and scoping literature reviews, and qualitative data collection (focus groups and interviews) with key health system actors, in Bac Giang province, Vietnam, to understand the barriers to maternal mental healthcare provision, utilisation, and integration strategies. A four-level framing of the barriers to integrating perinatal mental health services in Vietnam was used in reporting findings, which comprised individual, socio-cultural, organisational, and structural levels. At the socio-cultural and structural levels, these barriers included: cultural beliefs about the holistic notion of physical and mental health, stigma towards mental health, biomedical approach to healthcare services, absence of comprehensive mental health policy, and a lack of mental health workforce. At the organisational level, there was absence of clinical guidelines on the integration of mental health in routine antenatal visits, a shortage of staff, and poor health facilities. Finally, at the provider level, a lack of knowledge and training on mental health was identified. The integration of mental health into routine antenatal visits at the primary care level has the potential help to reduce stigma towards mental health and improve health system responsiveness by providing services closer to the local level, offering prompt attention, better choice of services, and better communication while ensuring privacy and confidentiality of services. This can improve the demand for mental health services and help reduce the delay of care-seeking.

Lack of awareness of systemic lupus erythematosus and its consequences in a cohort of moderate and severe patients in Spain: The LupusVoice study.

Systemic lupus erythematosus (SLE) is an autoimmune condition that can highly impact patients' quality of life (QoL). However, there is a lack of knowledge about SLE, affecting the general population and health care professionals (HCPs) alike. This lack of knowledge has negative implications for patients and the healthcare system, worsening prognosis, negatively impacting QoL, and increasing healthcare utilization. The aim of this paper is to draw attention, according to the perspective of the participants of this study, to the lack of awareness of SLE and its consequences in Spain, and to suggest improvements. This qualitative, descriptive, observational, multicenter, and cross-sectional study included 40 patients with moderate or severe SLE, recruited during their routine visits in six university hospitals in Spain. The study also included 11 caregivers and 9 HCPs. All participants were individually interviewed. Data from the interviews were coded and analyzed thematically by two anthropologists following a phenomenological perspective. Our study identified a lack of disease awareness among primary care physicians, emergency medicine doctors, and other specialists treating SLE symptomatology. This led to diagnostic delays, which had a clinical and emotional impact on patients. Furthermore, symptom awareness was found to be context dependent. Differences in symptom awareness between HCPs and patients led to a mismatch between the severity evaluation made by doctors and patients. Some HCPs did not consider the limitations of the current severity evaluation of SLE, and therefore attributed symptoms potentially caused by SLE to the unfavorable socioeconomic conditions patients lived in. Finally, a lack of social awareness among friends, family members, and romantic partners led to lower social support, increased isolation, and negative physical and emotional impact for patients. Gender differences in the provision of support were identified. This study highlights the need to increase SLE awareness among patients, HCPs, and the broader public in order to improve patient QoL. Being aware of the clinical and emotional impact of such lack of awareness, as well as the role played by context on the patient experience of SLE, is a crucial step towards achieving this goal.

Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance.

Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014-2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid.