Unscheduled Visits Research Articles

Close Collaboration with Parents Affects the Length of Stay and Growth in Preterm Infants: A Register-Based Study in Finland

Introduction: This study aimed to evaluate how Close Collaboration with Parents (CC), a neonatal intensive care unit (NICU)-wide educational model for healthcare staff to improve their family-centred care practices, affects the length of stay (LOS), growth, and later hospital visits and rehospitalizations of preterm infants. Methods: This register-based study included all preterm infants born below 35 weeks of gestation in Finland from 2006 to 2020. Eligible infants were classified into the Full Close Collaboration (Full-CC) group (n = 2,104) if the NICUs of both the delivery and discharge hospitals had implemented the intervention; into the Partial-CC group (n = 515) if only one of the NICUs had implemented the intervention; and into the control group (n = 11,621) if neither had implemented the intervention. Results: The adjusted LOS, the primary outcome, was 1.8 days or 6% shorter in the Full-CC group than in the control group (geometric mean ratio 0.94, 95% confidence interval [95% CI] 0.89–1.00). Growth was better in the Full-CC group compared to the control group: adjusted group difference 11.7 g/week (95% CI, 1.4–22.0) for weight, 1.3 mm/week (95% CI, 0.6–2.0) for length. The Full-CC group infants had lower odds of having any unscheduled outpatient visits compared to the control group (adjusted odds ratio 0.81; 95% CI, 0.67–0.98). No significant differences were found in any other comparisons. Discussion/Conclusion: The unit-wide intervention improving family-centred care practices in NICUs may lead to more efficient use of hospital resources by shortening the LOS, improving growth, and decreasing hospital visits of preterm infants.

Telehomecare: A Comprehensive Analysis of Its Relevance and Impact

The domestic conveyance of healthcare administrations to patients utilizing broadcast communications innovations that capture quiet clinical status estimations to empower and encourage timely instruction, data spread, social, emotional, and self-care support, as well as care administration by a healthcare professional at an outside location or unscheduled domestic visits based on require. This paper reviews the Telehomecare concepts, challenges, and constraints that need to be addressed for the successful implementation of the Telehomecare system. The narrative overview of the literature synthesizes the findings retrieved from searches of computerized databases, hand searches, and authoritative texts. The results have been summarized and categorized according to the parameters of the Telehomecare impact framework. This comprehensive analysis examines the relevance and impact of Telehomecare, highlighting its benefits, challenges, and future prospects. By understanding the implications of Telehomecare, healthcare systems can make informed decisions regarding its adoption and integration into existing care models.

Patient Opportunities to Self-Schedule in a Large Multisite, Multispecialty Medical Practice: Program Description and Uptake of 7 Unique Processes for Patients to Successfully Self-Schedule (and Reschedule) Their Medical Appointments.

Patient self-scheduling of medical appointments is becoming more common in many medical institutions. However, the complexity of scheduling multiple specialties, following scheduling guidelines, and managing appointment access requires a variety of processes for a diverse inventory of self-schedulable appointment types. From 7 unique patient self-scheduling methods, we captured counts of successfully self-scheduled and completed appointments. A process map was created to show the paths of 5 different primary self-scheduling processes (new appointment self-scheduling) and 2 secondary self-scheduling processes (existing appointment self-rescheduling). There were 7 unique processes that led to 733,651 successfully self-scheduled completed visits from January 1 to December 31, 2023 at a multisite, multispecialty clinic. The self-scheduling processes consisted of the following: (1) Ticket offer (appointment "ticket" offers for specific visits generated by a provider order or system rules), the software "ticket" sent to the patient permits "admission" to self-schedule calendar templates (341,591 uses, 46.6%); (2) direct self-scheduled visit for prequalified visit types (203,593 uses, 27.6%); (3) self-reschedule option (patient option to reschedule existing appointment, 79,706 uses, 10.9%); (4) new patient self-scheduled visit via clinic website (does not require portal access, 54,367 uses, 7.4%). (5) automated waitlist self-rescheduled visit (38,649 uses, 5.3%); (6) automated waitlist self-scheduled visit of previously unscheduled visit (10,939 uses, 1.5%); and (7) self-triage self-scheduled visit (4806 uses, 0.7%). The processes for self-scheduling are expanding. Our multispecialty clinic has implemented 7 different processes to help patients successfully self-schedule medical appointments. Some of the processes occur before initial scheduling (such as self-triage), and some are implemented after successful scheduling has already occurred (self-rescheduling option and self-rescheduling aided by an automated waitlist). Continued research is needed to look for measures of success beyond the ability to complete a self-scheduled visit, including the accuracy of the booking (right provider, location, and length of visit).

Efficacy of bronchial thermoplasty in a patient panel with uncontrolled severe persistent asthma

Background Bronchial thermoplasty (BT) is an approved procedure to manage uncontrolled severe persistent asthma. Many insurance providers are reluctant to pay for BT without proven benefit among their specific patient panel. Objective Determine if BT is effective in a panel patient panel with uncontrolled severe persistent asthma. Study design and methods This was an unblinded prospective study of adult subjects with uncontrolled severe persistent asthma who underwent BT. Outcomes were assessed at baseline and then 3-, 6-, 12-, 18- and 24-months post-BT. The primary metric was an improved Asthma Quality of Life Questionnaire (AQLQ) score. Other metrics included improved Asthma Control Test (ACT), peak expiratory flow rates (PEFR), spirometry, fractional excretion of nitric oxide (FeNO), number of unscheduled medical visits, and lost days of work/activity. Respiratory adverse events were assessed during the BT treatment period and at each post-BT visit. Results Twenty-nine subjects completed the study; the median interquartile range (IQR) age was 47 (42-61), and the majority were female (69%), white (93%), and non-Hispanic (90%). After BT, mean (±std) AQLQ scores improved by 1.6(±1.1) at 3 months (p < 0.0001), 1.6(±1.2) at 6 months (p < 0.0001), 1.4(±1.0) at 12 months (p < 0.0001), 1.8(±1.1) at 18 months (p < 0.0001), and 1.6 (±1.5) at 24 months (p < 0.0001). There were significant improvements in ACT, PEFR, unscheduled medical visits and lost days of work and activity. Spirometry and FeNO metrics were unchanged. The average cost for subjects completing all 3 BT procedures was approximately $15,000. Conclusion BT is an effective adjunctive therapeutic modality in subjects with uncontrolled severe persistent asthma.

The Burden of Care of Nasoalveolar Molding: An Institutional Experience.

Nasoalveolar molding (NAM) is an early presurgical intervention to facilitate primary cleft lip repair by reducing cleft severity and improving labial and nasal form. However, it continues to be associated with the burden of care that influences access and completion of therapy. The authors, therefore, aim to determine the burden of care of NAM therapy for families seeking treatment at a high-volume urban cleft center. A retrospective study of all patients undergoing primary cleft repair between 2012 and 2020 was performed. Patients were grouped based on whether or not NAM therapy was offered. Variables including physical, psychosocial, and financial factors were assessed. Two hundred and thirty patients underwent primary cleft repair between 2012 and 2020. Of these, 176 patients were indicated for NAM, with 4% discontinuing, and 54 patients did not undergo NAM. The 169 patients who completed NAM had a mean duration of treatment of 13.6±8.8 wks consisting of 15±6 scheduled NAM adjustment visits and 1±1 unscheduled visit made urgently to assess caregiver concerns. The mean travel distance was 28.6±37.1 miles. Eighty-four percent of caregivers were married, and 16% did not have English as a primary language. Though 57% had private insurance, 43% of patients received charity support for their treatment. NAM is a finite presurgical intervention that requires caregivers to participate in patient care for approximately three months of their early life. The decision to pursue NAM should be considered alongside the burden of care for caregivers to complete treatment.

Does Comorbid Food Allergy Affect Response to Omalizumab in Patients with Asthma?

The intrinsic link between food allergy and asthma is well-established, and comorbidity can exacerbate both conditions. Omalizumab, an anti-immunoglobulin E (IgE) antibody, has the biological plausibility to manage both conditions, but only a few small studies have assessed omalizumab in patients with comorbid asthma and food allergy. We conducted a post hoc analysis of placebo-controlled, randomized clinical trials (IA05 in children and 008/009 in adolescents/adults) and real-world observational studies (EXCELS and PROSPERO). For each study, patients with asthma were stratified by whether they had physician-reported food allergy, as per baseline characteristics data. For patients with comorbid food allergy, there was evidence for increased atopy at baseline (numerically higher total IgE levels and atopic comorbidities). The collective body of evidence found that omalizumab consistently improved general and asthma-specific patient-centered outcomes (food allergy-specific outcomes were not available). For patients with asthma, omalizumab improved healthcare resource use (emergency room visits, hospitalizations, unscheduled doctor visits), quality of life (asthma-specific Asthma Quality of Life Questionnaire), productivity (missed work/school days and the Work Productivity and Activity Impairment: Asthma), and asthma outcomes (asthma exacerbations and Asthma Control Test score) regardless of comorbid food allergy. There was no loss of omalizumab efficacy even though patients with both asthma and food allergy appeared to be generally more atopic. Omalizumab may be a viable management option for patients with these comorbidities. NCT00079937; NCT01922037; NCT00252135.

The Frequency and Common Causes of Unscheduled Adult Emergency Department Return Visits Within 72 Hours at King Fahad Specialist Hospital in Dammam: A Cross-Sectional Study

Background: Emergency Departments (ED) are becoming one of the most overcrowded departments globally. This study aims to investigate the frequency and causes of unscheduled patient return to the ED in King Fahad Specialist Hospital in Dammam (KFSH-D) within 72 hours of discharge. Method: This study is a cross-sectional retrospective study done between February and May, of 2023 at KFSH-D, Saudi Arabia. A total of 295 patients where included. Patients were selected using a simple random sampling technique. Medical record numbers (MRNs) of patients with unscheduled return visits within 72 hours were gathered from the hospital&amp;apos;s electronic medical record-integrated database (Medica Cloudcare) which were then entered on a random number generator. 295 MRNs were selected and included in the study. This study includes male and female patients older than 16 years who returned to the ED within 72 hours. Results: Results showed cancer as the most common comorbidity resulting in revisits within 72 hours. Regarding the emergency department triage category, category 3 was the most common category in revisiting patients (70.2%). Pain was the most common chief complain in the initial and second visit to emergency department, 61.0% and 61.4%, respectively. Most of the patients return due to patient-related causes, specifically no improvement (75.3%). Conclusion: The quality of patient care is negatively affected by the increasing patient demand. Although not much can be done for first visit patients, some simple actions could be done to reduce the rate of second visits.

Validity and performance of cognitive scales in elderly patients with depression in a tertiary care hospital in Chennai

Background: Late-life depression in older adults can cause reversible cognitive impairment, often resulting in pseudo-dementia. Cognitive impairment can lead to executive dysfunction, reduced flexibility, and difficulty thinking and decision-making. This study aimed to assess the validity and performance of cognitive scales in late-life depression among patients attending the outpatient department of the institute of mental health, Chennai. Methods: This prospective study included 360 patients aged &gt;50 years who were diagnosed with depression and attended the OPD at the institute of mental health, Chennai. Baseline assessments were performed at the time of recruitment into the study (visit 1), and scheduled visits were performed every six months for two years (visits 2 to 5). Unscheduled visits were done every month, and adverse events were monitored and recorded periodically Results: Among 59 patients, 53.1% were female, 32.2% were diabetic, and 93.9% were experiencing subjective working difficulties. The Montreal cognitive assessment scale classified 51.4% as moderate, while the ADAS-cog and ACE scales classified 86% and 99.7%, respectively, as having abnormal mental status. However, a significant correlation and discrepancy between scores were observed for scales such as ACE, ADAS-cog, standardised mini-mental status examination, and Montreal cognitive assessment scale. A strong correlation was found between ACE, MMSE, MoCA, and ACE; however, FAST showed a significant negative correlation. The MoCA was strongly correlated with the MMSE, ACE, ADAS-cog, and Mini-Cog, indicating good alignment with the FAST. Conclusions: Cognitive scales strongly correlate with late-life depression in patients, suggesting an improvement in assessment, evaluation, and treatment to address cognitive deficits.

Time toxicity associated with early phase clinical trial participation

Early phase cancer clinical trials (EPCTs) involve experimental drugs being used for the first time in humans. These studies are designed for dose determination and safety, and represent the most time intensive of all clinical trials for both clinicians and patients. We sought to quantify the amount of patient time consumed through EPCT participation. A retrospective audit of patients treated in the EPCT unit at Liverpool Hospital, Sydney was carried out from 2013 to 2023. We defined 'time toxicity' (TT) as a composite measure where time-toxic days were considered days with any health care system contact, including clinic visits, infusions, procedures or blood work. A total of 219 patients across 36 EPCTs were included. The median age was 65 years (range 31-81 years). Patients spent a median of 29% (range 4%-100%) of their days in direct contact with the health care system during their study. Protocol-specified visits accounted for the greatest contribution to total TT in 101 (46%) patients. In 7% (n= 16) of patients, unscheduled visits due to either adverse events or cancer-related symptoms accounted for the greatest TT. TT reduced as patients completed additional cycles of treatment. Patients who completed >10 cycles spent 14% of their days interacting with health care systems compared with 35% for those who completed ≤2 cycles. No statistically significant difference in TT was noted between dose-expansion and dose-escalation studies or trials focusing on immune-oncology versus targeted therapy. Our study is the first to report TT in EPCTs with an extended follow-up. Clinicians should be aware of TT when discussing risks and benefits. TT also may not be the appropriate term when describing the time patients invest during EPCTs. Toxicity implies a negative impact, but for many patients, trial participation would be seen as positive. There should be efforts to streamline health care visits to limit TT in EPCTs.

Identifying Causes of Unscheduled Healthcare Interactions and Changes to Patient Disposition in Individuals Receiving Outpatient Commercial Bispecific Antibody Therapy in Relapsed/Refractory Multiple Myeloma (RRMM)

Introduction: Teclistamab is a BCMA targeting bispecific antibody that was FDA approved for treating relapsed/refractory multiple myeloma (RRMM) based off the results of the MajesTEC-1 trial (Usmani S, et al. Lancet 2021, Moreau P, et al. N Engl J Med 2022), and is the first bispecific antibody approved for myeloma treatment. While patients included in the MajesTEC-1 study were monitored closely per trial protocols, little is known about what patient-reported care concerns and education gaps may exist outside of a trial setting with standard of care teclistamab and whether these gaps lead to a high number of unscheduled healthcare interactions. Methods: We retrospectively analyzed patient reported symptom concerns for commercial teclistamab patients at Memorial Sloan Kettering Cancer Center (MSKCC) via review of the electronic health record for a 4-month observation period following treatment initiation. Patients were included in the study if they had a response to teclistamab (per IMWG criteria), remained on treatment for at least 4 months as of our data cut-off (07/20/2023), and did not have evidence of disease progression during the observation period. Collected data included all unscheduled healthcare visits, including urgent care visits, emergency room visits, and hospital admissions. We also evaluated all outpatient communications, including telephone calls to physicians' offices and messages sent to physicians' offices through MSKCC's online patient portal. The total observation period included the first 4 months of therapy, during which patients were scheduled to receive treatment weekly and be seen by their physicians at regular 4-week intervals. Results: We identified 52 patients treated with teclistamab at our center as of the data cut-off, 19 of which met our inclusion criteria. Of note, this population had poorer performance status (89% vs 67% ECOG ≥1) and had more heavily pretreated disease (6 vs 5 median prior lines of therapy) when compared to the MajesTEC-1 population, with the majority not being eligible for MajesTEC-1 per its criteria. Within this population, 79% of patients communicated with their physicians' offices outside of their scheduled monthly appointments, with an average of 2.3 (0-8) communications sent per patient during the 4-month observation period. The most common reason for communication was upper respiratory tract infection (URI) symptoms, accounting for 24% of all communications. Other notable reasons included gastrointestinal (GI) symptoms (20%), disease related pain (13%), injection site reactions (9%) and symptoms of volume overload (9%). Unscheduled visits included 8 urgent care (UC) visits, and 20 emergency department (ED) visits involving 11/19 patients. The 20 ED visits led to 16 inpatient admissions, not including planned admissions for step-up dosing (data summarized in Figure 1), with a median length of stay of 4 days (2-24 days). URI symptoms triggered 50% of UC visits and 40% of the ED visits not leading to inpatient admission, but only accounted for 6% of hospital admissions. The most common cause of hospital admission was a non-URI acute infection (29%). Conclusions: Our data suggest that RRMM patients being treated with outpatient teclistamab have frequent unscheduled healthcare interactions. The high prevalence of URIs in our population indicates that infection rates in this frequently hypogammaglobulinemic patient population may be underreported. However, these do not frequently lead to inpatient admissions or to significant morbidity/mortality. Overall, teclistamab patients would likely benefit from improved patient education with regards to expected side effects of therapy, with pre-existing management plans in place for URIs, GI symptoms, and injection site reactions. Applying these principles may limit excessive healthcare visits for patients, particularly in those with heavily relapsed/refractory myeloma with poor disease prognosis. Data from additional patients, including patients receiving step-up dosing as outpatients as part of a pilot study, will be presented at the meeting.

Effects of Air Pollution on Respiratory Events and Pain Crises Among Children with Sickle Cell Disease in New York City

Introduction: Sickle cell disease (SCD) has the highest U.S. disease burden among Black and Hispanic populations, who more commonly live in urban areas with poor ambient air quality. The effect of air pollution exposure and social environmental factors on health outcomes in SCD have not been extensively studied, especially among children, and may further contribute to health disparities. Objectives: This study aims to examine the associations between air pollution exposure and acute respiratory and pain events and to determine whether neighborhood-level social disadvantage would modify their associations. Methods: We collected retrospective data on unscheduled outpatient visits, emergency department (ED) visits, and hospital admissions for respiratory events (i.e., respiratory tract infections, asthma exacerbation, acute chest syndrome) and vaso-occlusive pain crises requiring hospitalization (VOCs) for children with SCD in a tertiary care center in New York City (NYC) from 2015-2018. A total of 114 children with SCD (Table 1) were included in this study and had between 1-4 annual repeated measures of annual average air pollutants (i.e., black carbon (BC), fine particulate matter (PM 2.5), and nitrogen dioxide (NO 2)) with a total of 425 visits. Using home addresses, modeled data from the NYC Community Air Survey data were used to estimate street-level, annual average exposure to air pollution. The area deprivation index (ADI), a composite index of neighborhood-level social disadvantage, was dichotomized at the upper tertile (higher vs lower). Multivariable Poisson regression in generalized estimating equation (GEE) models were used to estimate relative risks (RR), after adjusting for potential covariates. Results: Overall, there were no significant associations between air pollution levels and acute respiratory and pain events among children with SCD. When stratified by ADI, increased exposure to PM 2.5 and NO 2, but not BC, was significantly associated with more frequent respiratory outpatient and ED visits among children residing in higher ADI neighborhoods (RR (95%CI)= 1.13 (1.00, 1.28) and 1.43 (1.01, 2.02) for PM 2.5 and NO 2, respectively, p&amp;lt;0.05 for all), but not among those in lower ADI neighborhoods (P-value for interaction=0.2 and 0.02 for PM 2.5 and NO 2, respectively) (Figure 1). Associations of air pollution with hospital admissions and VOCs were not observed for neither high ADI nor low ADI neighborhoods (p-value&amp;gt;0.05). Conclusions: Exposure to air pollutants increased respiratory complications among children living in deprived neighborhoods.

Effectiveness of a telenursing intervention program in reducing exacerbations in patients with chronic respiratory failure receiving noninvasive positive pressure ventilation: A randomized controlled trial.

Telenursing for patients with chronic respiratory failure receiving noninvasive positive pressure ventilation (NPPV) is an important aid in reducing exacerbations; however, there is insufficient evidence. This randomized controlled trial investigated the effectiveness of a telenursing intervention program in reducing exacerbations in patients with chronic respiratory failure receiving NPPV at home. We included patients receiving NPPV at home who could handle a tablet device. The intervention group (n = 15) underwent an information and communications technology-based telenursing intervention program in addition to usual care; the control group (n = 16) received the usual care only. The telenursing intervention program comprised telemonitoring and health counseling sessions via videophone. The intervention was evaluated once at enrollment and after 3 months. The primary endpoints were the number of unscheduled outpatient visits, hospitalizations, and hospital days. The secondary endpoints included the St. George's Respiratory Questionnaire (SGRQ) score, Euro QOL 5 Dimension score, Self-Care Agency Questionnaire (SCAQ) score, pulmonary function tests, and 6-min walking distance. We used the Mann-Whitney U test for our analysis. We found no significant differences between the intervention and control groups at enrollment. Then, the differences between the endpoints at baseline and 3 months after enrollment were calculated and used to compare both groups. At follow-up, the number of routine outpatient visits for acute exacerbations (p = .045), the number of hospitalizations (p = .037), the number of hospital days (p = .031), SGRQ (p = .039) score, and SCAQ (p = .034) score were significantly different. The increase in the number of unscheduled outpatient visits in the intervention group during follow-up was attributed to acute exacerbations and a significant decrease in the number of hospitalizations and hospital days. Hence, the telenursing intervention program may be effective in reducing exacerbations in patients with chronic respiratory failure receiving NPPV at home. Trial registration: UMIN Clinical Trials Registry (UMIN-CTR) UMIN000027657.

Targeted amplicon deep sequencing of ama1 and mdr1 to track within-host P. falciparum diversity throughout treatment in a clinical drug trial

Introduction Antimalarial therapeutic efficacy studies are routinely conducted in malaria-endemic countries to assess the effectiveness of antimalarial treatment strategies. Targeted amplicon sequencing (AmpSeq) uniquely identifies and quantifies genetically distinct parasites within an infection. In this study, AmpSeq of Plasmodium falciparum apical membrane antigen 1 (ama1), and multidrug resistance gene 1 (mdr1), were used to characterise the complexity of infection (COI) and drug-resistance genotypes, respectively. Methods P. falciparum-positive samples were obtained from a triple artemisinin combination therapy clinical trial conducted in 30 children under 13 years of age between 2018 and 2019 in Kilifi, Kenya. Nine of the 30 participants presented with recurrent parasitemia from day 26 (624h) onwards. The ama1 and mdr1 genes were amplified and sequenced, while msp1, msp2 and glurp data were obtained from the original clinical study. Results The COI was comparable between ama1 and msp1, msp2 and glurp; overall, ama1 detected more microhaplotypes. Based on ama1, a stable number of microhaplotypes were detected throughout treatment until day 3. Additionally, a recrudescent infection was identified with an ama1 microhaplotype initially observed at 30h and later in an unscheduled follow-up visit. Using the relative frequencies of ama1 microhaplotypes and parasitemia, we identified a fast (&lt;1h) and slow (&gt;5h) clearing microhaplotype. As expected, only two mdr1 microhaplotypes (NF and NY) were identified based on the combination of amino acid polymorphisms at codons 86 and 184. Conclusions This study highlights AmpSeq as a tool for highly-resolution tracking of parasite microhaplotypes throughout treatment and can detect variation in microhaplotype clearance estimates. AmpSeq can also identify slow-clearing microhaplotypes, a potential early sign of selection during treatment. Consequently, AmpSeq has the capability of improving the discriminatory power to distinguish recrudescences from reinfections accurately.

A peer-led learning program about intimate and romantic relationships for persons with mental disorders (AIRIKI): co-creation pilot feasibility study

BackgroundIntimate and romantic relationships are important in life for individuals, irrespective of mental health status. We developed a four-hour peer-led learning program for persons with mental disorders about intimate and romantic relationships through a co-creation process with service users and examined its preliminary effectiveness and feasibility of implementing the program.MethodsA one-group pretest–posttest trial was conducted using a mixed-method design for 45 individuals with mental disorders in Japan. Outcome data were collected at three time points: baseline, post-intervention, and one month after program completion. Mixed models for repeated measures (MMRM) were used to examine changes over time in the Rosenberg Self-Esteem Scale (RSES), Recovery Assessment Scale (RAS), Herth Hope Index (HHI), and the original items. Group interviews were conducted for process evaluation.ResultsMMRM showed significant changes over time on RSES, RAS, HHI, and two original items “I am able to communicate well with others about myself” and “I am able to listen to others well.” In multiple comparisons, RSES and HHI were significant one month after the program. Participants reported changes during the first month after attending the program in terms of their positive attitude toward romantic relationships (n = 14), taking romantic actions (n = 11), and feeling their overall communication improved (n = 11). Although two participants had an unscheduled psychiatric visit that could be attributed to attending the program, all recovered after one month.ConclusionsThe program exhibited preliminary effectiveness to a moderate extent in improving recovery, particularly regarding self-esteem and hope. The program is feasible but requires further modifications regarding inclusion criteria for participants and the training of peer facilitators.Trial registrationUMIN000041743;09/09/2020.

Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study.

Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation. This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics. Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis. Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases. Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers

BackgroundPublic assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan.MethodsThis retrospective cohort study included public assistance recipients from two municipalities. We obtained participants’ sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants’ unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants’ age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined.ResultsWe identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00–2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00–3.59) and with children (IR 2.35, 95% CI 1.11–4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41–1.35) and those living with children (IR 0.50, 95% CI 0.20–1.23). A higher frequency in asthma visits was observed among working recipients living with family.ConclusionsWorking adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

Emergency Department Frequentation and Unscheduled Visits of Liver Transplant Patients: Ten Years Experience in Tertiary Care Center, Saudi Arabia.

Introduction and objectives Liver transplantation and its indications represent an increased burden on patients' health. This can be represented in a variety of ways, such as in emergency visits, unscheduled clinic visits, and unanticipated admissions. This study aims to analyze emergency department (ED) visits, the most common presenting complaints, and the outcomes of those visits. Methods A retrospective observational study was performed in which electronic medical records were reviewed for all patients who underwent liver transplantation and presented to the emergency department between October 2011 and October 2021. The following data were collected: demographics, comorbidities, liver transplant features, and emergency department visit data and outcomes. Recurrent visits were assessed and labeled as first, second, third, fourth, and fifth or more. Results A total of 699 patients and 5,225 visits were included in the analysis. Living donors accounted for 80% of all transplants. The mean post-operative length of stay was 22.6 ± 17.8. The majority of patients (74%) had at least one comorbidity, with diabetes (47%), hypertension (31%), and chronic kidney disease (CKD) (16%) being the commonest comorbidities; however, comorbidities were not associated with an increased risk of emergency department visits. Out of the 5,225 visits to the emergency department, 2,265 (41%) were within the first year. Emergency department visits in the first seven days after discharge amounted to 22% of total first visits. By 30 days, six months, and one year, they increased to 46%, 83%, and 91%, respectively. Living donor recipients had an average of 7.3 ED visits as compared to deceased donor recipients, who had an average of 8.4 ED visits. The most common presenting complaints were gastrointestinal (GI) symptoms (18%), infectious disease symptoms (9%), and respiratory symptoms (8%). There were a total of 296 patients who were readmitted at least once since discharge after liver transplantation. Conclusion The majority of first-time presentations to ED occurred in the first year post-transplant, marking this time period as critical for liver transplant patients. Our study also highlighted the continual presentations of liver transplant patients to the ED a few years post-transplant. This requires close scrutiny of the main causes of such presentations as well as comparison with other transplant cases to identify whether they are specific to liver transplants or not.

Clinical Subtypes of Neutrophilic Asthma: A Cluster Analysis From Australasian Severe Asthma Network

Clinical heterogeneity may exist within asthma subtypes defined by inflammatory markers. However, the heterogeneity of neutrophilic asthma (NA) remains largely unexplored. To explore potential clusters and the stability of NA. Participants with NA from the Australasian Severe Asthma Network underwent a multidimensional assessment. They were then asked to participate in a 12-month longitudinal cohort study. We explored potential clusters using a hierarchical cluster analysis and validated the differential future risk of asthma exacerbations in the identified clusters. A decision tree analysis was developed to predict cluster assignments. Finally, the stability of prespecified clusters was examined within 1 month. Three clusters were identified in 149 patients with NA. Cluster 1 (n= 99; 66.4%) was characterized by female-predominant nonsmokers with well-controlled NA, cluster 2 (n= 16; 10.7%) by individuals with comorbid anxiety/depressive symptoms with poorly controlled NA, and cluster 3 by older male smokers with late-onset NA. Cluster 2 had a greater proportion of participants with severe exacerbations (P= .005), hospitalization (P= .010), and unscheduled visits (P= .013) and a higher number of emergency room visits (P= .039) than that of the other two clusters. The decision tree assigned 92.6% of participants correctly. Most participants (87.5%; n= 7) in cluster 2 had a stable NA phenotype, whereas participants of clusters 1 and 3 had variable phenotypes. We identified three clinical clusters of NA, in which cluster 2 represents an uncontrolled and stable NA subtype with an elevated risk of exacerbations. These findings have clinical implications for the management of NA.

The risk factors of the 72-h unscheduled return visit admission to emergency department in adults below 50 years old

BackgroundAn unscheduled return visit (URV) to the emergency department (ED) within 72-h is an indicator of ED performance. An unscheduled return revisit (URV) within 72-h was used to monitor adverse events and medical errors in a hospital quality improvement program. The study explores the potential factors that contribute to URV to the ED within 72-h and the unscheduled return revisit admission (URVA) in adults below 50 years old.MethodsThe case–control study enrolled 9483 URV patients during 2015–2020 in National Cheng-Kung University Hospital. URVA and URV non-admission (URVNA) patients were analyzed. The Gini impurity index was calculated by decision tree (DT) to split the variables capable of partitioning the groups into URVA and URVNA. Logistic regression is applied to calculate the odds ratio (OR) of candidate variables. The α level was set at 0.05.ResultsAmong patients under the age of 50, the percentage of females in URVNA was 55.05%, while in URVA it was 53.25%. Furthermore, the average age of URVA patients was 38.20 ± 8.10, which is higher than the average age of 35.19 ± 8.65 observed in URVNA. The Charlson Comorbidity Index (CCI) of the URVA patients (1.59 ± 1.00) was significantly higher than that of the URVNA patients (1.22 ± 0.64). The diastolic blood pressure (DBP) of the URVA patients was 85.29 ± 16.22, which was lower than that of the URVNA (82.89 ± 17.29). Severe triage of URVA patients is 21.1%, which is higher than the 9.7% of URVNA patients. The decision tree suggests that the factors associated with URVA are “severe triage,” “CCI higher than 2,” “DBP less than 86.5 mmHg,” and “age older than 34 years”. These risk factors were verified by logistic regression and the OR of CCI was 2.42 (1.50–3.90), the OR of age was 1.84 (1.50–2.27), the OR of DBP less than 86.5 was 0.71 (0.58–0.86), and the OR of severe triage was 2.35 (1.83–3.03).ConclusionsThe results provide physicians with a reference for discharging patients and could help ED physicians reduce the cognitive burden associated with the diagnostic errors and stress.

Opioid-free percutaneous nephrolithotomy: an initial experience.

The opioid epidemic in the United States is an ongoing public health crisis that is in part fueled by excessive prescribing by physicians. Percutaneous nephrolithotomy (PCNL) is a procedure that conventionally involves opioid prescriptions for adequate post-operative pain control. We aimed to evaluate the feasibility of a non-opioid pain regimen by evaluating post-operative outcomes in PCNL patients discharged without opioids. As a quality improvement measure to reduce opioid consumption our department began routinely prescribing oral ketorolac instead of oxycodone-acetaminophen for pain control after PCNL. We retrospectively compared patients undergoing PCNL who had received ketorolac prescriptions (NSAID) to those who received oxycodone-acetaminophen prescriptions (NARC). Demographic, operative, and post-operative factors were obtained and compared in both groups. Peri-operative factors and demographics were compared using either Chi-squared tests, Mann-Whitney U tests. Surgical outcomes were compared between the two groups using Chi-squared tests and Fisher's exact tests. Multivariate logistic regression analysis was performed to determine whether ketorolac use was an independent predictor of post-surgical pain-related encounters. Primary outcome was unplanned pain-related healthcare encounters inclusive of office phone calls, unscheduled office visits, and emergency department (ED) visits. Secondary outcome measures were non-pain-related healthcare encounters, hospital readmissions, pain-related rescue medications prescribed, and post-op complications. There were similar demographics and peri-operative characteristics amongst patients in both cohorts. There was no significant difference identified between NSAID and NARC regarding unplanned pain-related encounters (8/70, 11.4% vs. 10/70, 14.3%, p = 0.614). However, NARC experienced more unplanned phone calls (42, 60% vs. 24, 34.3%, p = 0.004). Multivariate analysis revealed only prior stone surgery was predictive of pain-related encounters after PCNL (p = 0.035). Our results show that there were no significant differences in pain-related encounters between those who received ketorolac and oxycodone-acetaminophen following PCNL. A non-opioid pathway may mitigate the potential risk associated with opioid prescription without compromising analgesia. Prospective comparative studies are warranted to confirm feasibility.