Urgent Hospital Research Articles

Outpatient encounters, continuity of care, and unplanned hospital care for children and young people with cerebral palsy.

To describe the relationships between outpatient encounters, continuity of care, and unplanned hospital care in children/young people with cerebral palsy (CP). In this population-based data-linkage cohort study we included children/young people with CP identified in the New South Wales/Australian Capital Territory CP Register (birth years 1994-2018). We measured the frequency of outpatient encounters and unplanned hospital care, defined as presentations to emergency departments and/or urgent hospital admissions (2015-2020). Continuity of outpatient care was measured using the Usual Provider of Care Index (UPCI). Of 3267 children/young people with CP, most (n = 2738, 83.8%, 57.6% male) had one or more outpatient encounters (123 463 total encounters, median six outpatient encounters per year during childhood). High UPCI was more common in children/young people with mild CP (Gross Motor Function Classification System levels I-III, with no epilepsy or no intellectual disability), residing in metropolitan and areas of least socioeconomic disadvantage. Low UPCI was associated with four or more emergency department presentations (adjusted odds ratio [aOR] 2.34; 95% confidence interval [CI] 1.71-3.19) and one or more urgent hospital admissions (aOR 2.02; 95% CI 1.57-2.61). Children/young people with CP require frequent outpatient services. Improving continuity of care, particularly for those residing in regional/remote areas, may decrease need for unplanned hospital care. Many children with cerebral palsy use multiple and frequent outpatient services. Better continuity of care is associated with living in metropolitan and less socioeconomically disadvantaged areas. Outpatient service utilization reduces at the time of transition to adult services. High outpatient utilization is associated with unplanned hospital care. Decreased continuity of care is associated with unplanned hospital care.

Associations of fasting state glycemic biomarkers with mortality and morbidity in heart failure: Retrospective cohort study

Abstract Background Diabetes mellitus (DM) is a common comorbidity among heart failure (HF), complicated with 10% to 47% of HF patients. DM is also known to be associated with cardiovascular mortality and hospitalization for heart failure (HHF) in HFpEF and HFrEF. Though HbA1c is the most used glycemic control target, whether HbA1c is the most appropriate glycemic control marker remains to be investigated. Purpose To evaluate relationships between clinical outcomes and glycemic markers among heart failure patients, including HbA1c, HOMA-β and HOMA-IR. Methods We retrospectively evaluated the relationships between fasting state glycemic markers, including HbA1c, HOMA-β and HOMA-IR, and clinical outcomes in heart failure patients admitted to our hospital from 2016 to 2020. These glycemic markers were calculated from fasting blood glucose and insulin concentrations. The primary outcome was composite of all cause death or HHF. Multivariate Cox regression proportional hazards models were used to assess the relationship between glycemic markers and clinical outcomes, adjusting for age, sex, DM, BMI, ischemic etiology, eGFR, log-transformed BNP and urgent hospitalization. Results 682 patients were included in the analyses. Median age was 70 years (IQR 59 to 77 years), and 66% were male. 41% patients had left ventricular ejection fraction below 40%, and 32% had DM. The median follow-up periods were 16.5 months (IQR 4.4 to 37.3 months). HOMA-IR was independently associated with the primary outcome (HOMA-IR 1.0 to 2.5: HR1.34, 95%CI 0.79 to 2.28, p = 0.27; HOMA-IR 2.5 to 10: HR2.19, 95%CI 1.30 to 3.66, p = 0.003; HOMA-IR >10: HR2.92, 95%CI 1.61 to 5.30, p<0.001), but HbA1c and HOMA-β were not associated with the primary outcome (HbA1c 6.0 to 7.0: HR0.99, 95%CI 0.70 to 1.38, p = 0.94; HbA1c 7.0 to 8.0: HR0.80, 95%CI 0.48 to 1.34, p = 0.39; HbA1c >8.0: HR1.02, 95%CI 0.48 to 2.20, p = 0.95; HOMA-β <30: HR0.98, 95%CI 0.64 to 1.51, p = 0.94) (figure 1). Receiver-operator characteristics curve analysis revealed that HOMA-IR (AUC 0.60, 95%CI 0.55 to 0.65) had a significantly better predictive value for the primary outcome compared with HbA1c (AUC 0.56, 95%CI 0.51 to 0.61) and HOMA-β (AUC 0.51, 95%CI 0.46 to 0.56) (Figure 2). Conclusion Among fasting state glycemic biomarkers, HOMA-IR was independently associated with mortality and morbidity in HF, but HbA1c and HOMA-β were not. HOMA-IR may aid better DM managements among HF patients beyond current HbA1c targeted DM managements.Adjusted hazard ratio of glycemic markerROC analysis for the primary outcome

Prognostic value of three-dimensional regurgitant orifice determination in functional mitral regurgitation

Abstract Background Functional mitral regurgitation (FMR) evaluation using effective regurgitant orifice (ERO) by echocardiography remains controversial. Given the morphology of regurgitant jets in FMR, determination of ERO using three-dimensional transesophageal echocardiography (3D-TEE) may be more accurate. However, a clear threshold for this parameter has not been defined. Purpose Our aim is to evaluate the prognostic value of 3D-ERO in FMR. Methods All patients with at least moderate FMR who underwent 3D-TEE in a tertiary center between 2016 and 2020 were retrospectively selected. Echocardiographic variables by transthoracic and transesophageal, as well as demographic and clinical history variables, were collected. A combined event of urgent hospital admission or death was considered. Variables statistically associated with the event were included in multivariate analysis. Results 112 patients (74 men (66.1%), mean age 72.3±10.9 years) were finally included. The most frequent etiology of FMR was ventricular dysfunction (61.6%), followed by annular dilation (23.2%) and posterior leaflet restriction (15.2%). The mean 3D-ERO was 0.53±0.25 cm2 and mean ejection fraction was 40.7±14.2%. At diagnosis, 49 patients (43.8%) were not receiving diuretics, 63 (56.2%) had atrial fibrillation/flutter, 60.3% permanent. FMR was treated in 54 patients (48.2%), 61,1% percutaneously. During a follow-up of 36 [14-54] months, 50 (44,6%) patients were urgently hospitalized (mean 1.9±2.8 admissions) and 49 (43,8%) died, received a heart transplant or LVAD. 3D-ERO was significantly associated with the occurrence of the event (0.55 vs 0.41; p=0.02). Additionally, 3D-ERO was associated with mitral intervention (0.58 vs 0.47 cm2; p=0.01) and had a trend towards death from any cause (0.56 vs 0.5 cm2; p=0.098). The prognostic capacity of 3D-ERO for the combined event was determined using an ROC curve (Figure). An AUC of 0.67 (95% CI 0.55-0.8; p=0.01) and an optimal cutoff value of 0.45 cm2 (sensitivity 0.62, specificity 0.73) were obtained. In univariate analysis, the combined event was also associated with age (73.9 vs. 65.6 years; p=0.01), diabetes (40 vs. 13.6%; p=0.02), chronic kidney disease (42.7 vs. 13.6%; p=0.01), ischemic heart disease (59.6 vs 31,8%, p=0.02) and daily furosemide dose (39.7 vs. 13.6 mg; p<0.01). In multivariate analysis of the event, age, daily furosemide dose, ischemic heart disease and 3D-ERO were included in the final predictive model (Table). Conclusions In patients with FMR, 3D-ERO was significantly associated with the occurrence of events during follow-up, with an optimal prognostic performance cutoff point of 0.45 cm2. Furthermore, it was an independent predictor of mitral intervention and included among the predictors of urgent hospital admission or death. Therefore, 3D-ERO may be useful in risk stratification of FMR.

Heart failure early post-discharge appointment: a 1.5-year single-centre experience

Abstract Background According to Heart Failure (HF) guidelines, a follow-up visit should be conducted within 1 to 2 weeks after hospital discharge to monitor signs and symptoms of HF, optimize therapy, and evaluate treatment side effects. Retrospective studies have shown that this approach is associated with lower 30-day readmission rates. Purpose Our aim is to describe the role of early post-discharge appointment in the management of HF patients and to evaluate prognostic factors after HF hospitalization. Methods We conducted a single-centre prospective registry of consecutive patients evaluated in the early post-discharge appointment at our centre, from March 2021 to September 2022. HF symptoms, vital signs, blood test results, treatment decision, and 90-day HF events were recorded. Results Overall, 153 patients were included (mean age 65.7 ± 13.0 years, 63.4% male). The mean time from hospital discharge to post-discharge appointment was 13.4 ± 5.7 days. Left ventricle ejection fraction was reduced in 83.6% (n = 127) of patients. Guideline-directed medical treatment prescribed at discharge, as well as up-titration and withdrawal patterns at the post-discharge appointment, are presented in Table 1. At the post-discharge appointment, 34.3% of patients (n = 35) presented with drug adverse effects, most often including hyperkalemia (17.5%, n = 22), acute kidney injury (9.9%, n = 12), and hypotension (3.9%, n = 6). Of those evaluated at the post-discharge appointment, 11.2% (n = 17) were scheduled to another appointment one week later, for early re-evaluation, 90.1% (n = 137) were followed-up in the standard HF ambulatory program, and 2.6% (n = 4) were hospitalized. The serum creatinine (1.10 [0.87 – 1.36] mg/dL vs 1.40 [1.09 – 1.95] mg/dL, p<0.001), the serum C cystatin (1.50 [1.25 – 1.98] mg/dL vs 1.97 [1.54 – 2.46] mg/dL, p = 0.007) and the NT-proBNP levels (1859 [977 – 4877] mg/dL vs 5928 [2817 – 11957] mg/dL, p = 0.013), measured at the time of the post-discharge appointment, were found to be associated with HF events within 90 days (urgent HF visit or HF hospitalization). An NT-proBNP level above 2400 pg/mL adjusted to C cystatin was found to be a strong predictor of 90-day HF events (OR 9.855, 95% CI 2.657 – 36.550, p = 0.001). This model yielded a good prognostic performance (AUC 0.790, CI 95% 0.689-0.890, p<0.001). Conclusions Early evaluation of HF patients after hospital discharge allows for guideline-directed medical therapy up-titration and early detection of drug adverse effects. The NTproBNP level and kidney function, assessed early after discharge, have been found to be strong predictors of 90-day HF events, indicating which patients would benefit most from a stricter follow-up program. Table 1 – Guideline-directed medical therapy patterns of prescription both at hospital discharge and during the early post-discharge appointment. ACE, angiotensin converting enzyme; ARA, aldosterone receptor antagonist, MRA, mineralocorticoid receptor antagonist.

Abstract 17940: Effects of Continuous Accelerated Pacing on Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction: Three Year Follow Up of the myPACE Randomized Clinical Trial

Background: Heart failure with a preserved ejection fraction (HFpEF) is prevalent and has few evidence-based therapies. In a trial of HFpEF patients with specialized pacemakers, an accelerated personalized pacing rate averaging 75 bpm (myPACE) improved quality of life, NT-proBNP, physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60bpm (usual care). The one-year myPACE trial was not powered for clinical outcomes, but most patients elected to remain on their assigned treatment. Methods: The myPACE study was a single-center, blinded, randomized controlled trial that enrolled patients from June 2019 to November 2020. In this per-protocol analysis of clinical events over a 3-year follow-up, we included trial participants who remained on their assigned heart rate after study completion. The outcome of this analysis is a composite of the first clinical event (urgent visit or hospitalization for heart failure or atrial fibrillation, unstable angina or myocardial infarction, stroke, and death). Events were obtained by chart review and adjudicated by two blinded investigators. A Kaplan-Meier event-free survival plot and a log-rank test evaluated differences between the two treatment arms. Results: Of the 100 myPACE trial participants, most (40/48 myPACE and 48/52 usual care) remained on their assigned heart rate over a median (IQR) of 3.3 (2.6, 3.7) years after enrollment. The median (IQR) age was 75(69-80), and 45% were female. Accelerated personalized pacing was associated with reduced adverse clinical outcomes by about 60 percent. The Kaplan-Meier event-free survival plot for the composite of clinical events is shown in the Figure. Conclusions: In a per-protocol clinical event analysis of the extended myPACE study, those who continued the myPACE accelerated pacing protocol had fewer adverse clinical events than those with a lower rate setting of 60 bpm.

Infants, children, youth and young adults with a serious illness in British Columbia: a population-based analysis using linked administrative data.

Pediatric palliative care aims to improve quality of life among infants, children, youth and young adults with serious illnesses, sometimes over years, but estimates of infants, children, youth and young adults requiring pediatric palliative care have been highly variable and need refinement. We sought to describe this population in British Columbia and identify clinical instability to inform program planning in pediatric palliative care. We conducted a population-based analysis using linked administrative health data from 2012/13 to 2016/17. We applied a coding framework validated in the United Kingdom to estimate the number of BC residents aged 0-25 years with serious illnesses and to identify 5 clinical stages. We describe demographics, estimate prevalence and model risk of instability, defined as having urgent hospital admissions, admissions to the intensive care unit or death. About 2500 infants, children, youth and young adults were admitted to hospital with a serious illness diagnosis each study year, of which around 50% were infants, 60% or so of whom had perinatal or congenital diagnoses. Compared with children aged 1-4 years, infants had the highest risk of instability (odds ratio [OR] 6.59, 95% confidence interval [CI] 5.97-7.29). Compared with oncology patients, infants, children, youth and young adults with neurological (OR 1.43, 95% CI 1.21-1.70) and otherwise specified diagnoses (OR 1.55, 95% CI 1.39-1.73) had a higher risk of instability. The population of infants, children, youth and young adults with serious illnesses in BC is substantially larger than that currently receiving pediatric palliative care. Future planning of these services needs to consider expanding its reach, focusing particularly on infants and other subpopulations with high risk of instability.

Predicting COVID-19 Hospital Stays with Kolmogorov–Gabor Polynomials: Charting the Future of Care

Optimal allocation of ward beds is crucial given the respiratory nature of COVID-19, which necessitates urgent hospitalization for certain patients. Several governments have leveraged technology to mitigate the pandemic’s adverse impacts. Based on clinical and demographic variables assessed upon admission, this study predicts the length of stay (LOS) for COVID-19 patients in hospitals. The Kolmogorov–Gabor polynomial (a.k.a., Volterra functional series) was trained using regularized least squares and validated on a dataset of 1600 COVID-19 patients admitted to Khorshid Hospital in the central province of Iran, and the five-fold internal cross-validated results were presented. The Volterra method provides flexibility, interactions among variables, and robustness. The most important features of the LOS prediction system were inflammatory markers, bicarbonate (HCO3), and fever—the adj. R2 and Concordance Correlation Coefficients were 0.81 [95% CI: 0.79–0.84] and 0.94 [0.93–0.95], respectively. The estimation bias was not statistically significant (p-value = 0.777; paired-sample t-test). The system was further analyzed to predict “normal” LOS ≤ 7 days versus “prolonged” LOS > 7 days groups. It showed excellent balanced diagnostic accuracy and agreement rate. However, temporal and spatial validation must be considered to generalize the model. This contribution is hoped to pave the way for hospitals and healthcare providers to manage their resources better.

Emergency surgical pathology in pregnant women and women in labor: analysis of the structure of morbidity and routing paths in St. Petersburg

Relevance. Today, despite the development of medical technologies and the improvement of the logistical aspects of healthcare, the problem of unified treatment, diagnostic and routing algorithms for pregnant women and women in labor with urgent surgical pathology remains unresolved. The first step towards its solution is a detailed analysis of the current structure of incidence and routing paths.The objective was to analyze the incidence of urgent extragenital surgical pathology and routing paths in pregnant women and women in labor in St. Petersburg.Methods and materials. Based on the database of invoices issued by insurance organizations in St. Petersburg for completed cases of treatment, we performed a retrospective analysis of the data of pregnant patients with extragenital surgical pathology, hospitalized on an emergency basis in the period from 2019 to 2021. We assessed the structure of morbidity, terms of delivery to the hospital, indications and range of surgical interventions, treatment outcomes.Conclusions. In the structure of urgent and emergency hospitalizations in pregnant women, extragenital surgical pathology is 1 %. The total proportion of surgical interventions in patients with extragenital pathology is 35.1 %. Routing of a pregnant woman with suspected surgical pathology through the primary visit to the maternity hospital significantly increases (p<0.05) the average time to admission to the surgical hospital. > <0.05 ) the average time to admission to the surgical hospital.

MicroDoc: Developing a guide for managing infections in Zambian rural low-resource health settings

Abstract Lack of access to diagnostic tests and guidelines that are inappropriate for poorly resourced facilities can result in incorrect and excessive prescribing of antimicrobial therapy in rural healthcare settings. On Call Africa (OCA) and Virtual Doctors (VD) are two non-governmental organisations that work in healthcare in Zambia. Volunteers and staff from OCA and VD have collaborated with the Zambian Ministry of Health and local healthcare providers to design a guide to support decisions around management of infections specifically in rural primary healthcare settings in Zambia. Local staff were initially surveyed for their attitudes towards treatment of infections, the content they would like capacity building in, and preferred modes of learning. The team, comprising public health and infectious disease doctors and GPs from Ireland and the UK with experience working in Zambia, have created a guide called MicroDoc which encompasses workshops, PDFs, flowcharts and modules relating to management of infections and antimicrobial prescribing. All the content can be downloaded and accessed offline. The Zambian Standard Treatment Guidelines were consulted for antimicrobial choice, supplemented by NICE and WHO where necessary. Red flags for urgent hospital referral are also incorporated, as well as modules about risks of antimicrobial resistance. Early versions of the guide have been distributed to a range of facilities in Zambia's Southern Province, with promising feedback from healthcare providers. In collaboration with local partners and input from facility staff, MicroDoc will be finalised and rolled out to more health posts and health centres in the region, with a view to eventually expanding to other regions. The OCA team has been conducting clinical audits of prescribing practices in two rural health posts and it is hoped that the MicroDoc guide will contribute to improved antimicrobial stewardship as well as better outcomes for patients. Key messages • Management of infectious presentations is particularly challenging in rural low-resource primary healthcare settings in Sub-Saharan countries such as Zambia. • A team from On Call Africa and Virtual Doctors has created a guide called MicroDoc, in collaboration with Zambian health authorities, to support decision making in managing infections in primary care.

Interpretable machine learning accurately reclassifies lobectomy surgical approaches by cost

BackgroundThe volume of robotic lung resection continues to increase despite its higher costs and unproven superiority to video-assisted thoracoscopic surgery. We evaluated whether machine learning can accurately identify factors influencing cost and reclassify high-cost operative approaches into lower-cost alternatives. MethodsThe Florida Agency for Healthcare Administration and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets were queried for patients undergoing open, video-assisted thoracoscopic surgery and robotic lobectomy. K-means cluster analysis was used to identify robotic clusters based on total cost. Predictive models were built using artificial neural networks, Support Vector Machines, Classification and Regression Trees, and Gradient Boosted Machines algorithms. Models were applied to the high-volume robotic group to determine patients whose cost cluster changed if undergoing a video-assisted thoracoscopic surgery approach. A local interpretable model-agnostic explanation approach personalized cost per patient. ResultsOf the 6,618 cases included in the analysis, we identified 4 cost clusters. Application of artificial neural networks to the robotic subgroup identified 1,642 (65%) cases with no re-assignment of cost cluster, 583 (23%) with reduced costs, and 300 (12%) with increased costs if they had undergone video-assisted thoracoscopic surgery approach. The 5 overall highest cost predictors were patient admission from the clinic, diagnosis of metastatic cancer, presence of cancer, urgent hospital admission, and dementia. ConclusionK-means cluster analysis and machine learning identify a patient population that may undergo video-assisted thoracoscopic surgery or robotic lobectomy without a significant difference in total cost. Local interpretable model-agnostic explanation identifies individual patient factors contributing to cost. Application of this modeling may reliably stratify high-cost patients into lower-cost approaches and provide a rationale for reducing expenditure.

In-depth biological characterization of two black soldier fly anti-Pseudomonas peptides reveals LPS-binding and immunomodulating effects.

As effector molecules of the innate immune system, antimicrobial peptides (AMPs) have gathered substantial interest as a potential future generation of antibiotics. Here, we demonstrate the anti-Pseudomonas activity and lipopolysaccharide (LPS)-binding ability of HC1 and HC10, two cecropin peptides from the black soldier fly (Hermetia Illucens). Both peptides are active against a wide range of Pseudomonas aeruginosa strains, including drug-resistant clinical isolates. Moreover, HC1 and HC10 can bind to lipid A, the toxic center of LPS and reduce the LPS-induced nitric oxide and cytokine production in murine macrophage cells. This suggests that the peptide-LPS binding can also lower the strong inflammatory response associated with P. aeruginosa infections. As the activity of AMPs is often influenced by the presence of salts, we studied the LPS-binding activity of HC1 and HC10 in physiological salt concentrations, revealing a strong decrease in activity. Our research confirmed the early potential of HC1 and HC10 as starting points for anti-Pseudomonas drugs, as well as the need for structural or formulation optimization before further preclinical development can be considered. IMPORTANCE The high mortality and morbidity associated with Pseudomonas aeruginosa infections remain an ongoing challenge in clinical practice that requires urgent action. P. aeruginosa mostly infects immunocompromised individuals, and its prevalence is especially high in urgent care hospital settings. Lipopolysaccharides (LPSs) are outer membrane structures that are responsible for inducing the innate immune cascade upon infection. P. aeruginosa LPS can cause local excessive inflammation, or spread systemically throughout the body, leading to multi-organ failure and septic shock. As antimicrobial resistance rates in P. aeruginosa infections are rising, the research and development of new antimicrobial agents remain indispensable. Especially, antimicrobials that can both kill the bacteria themselves and neutralize their toxins are of great interest in P. aeruginosa research to develop as the next generation of drugs.

COVID-19 lockdown effect on healthcare utilization and in-hospital mortality in children under 5 years in Cape Town, South Africa: a cross-sectional study.

COVID-19 pandemic measures resulted in the de-escalation of non-COVID-19 healthcare provision. A retrospective cross-sectional study of routinely collected data was done to investigate the effect of COVID-19 policies on the healthcare utilization and mortality of children younger than 5 years in Eastern Cape Town, South Africa. We compared visits to primary and urgent care facilities, hospitalization, in-hospital deaths, and vaccine uptake from 1 January to 31 December 2020 to similar periods in 2018 and 2019. During April and May 2020, the most restricted period, visits to primary care facilities declined from 126 049 in 2019 to 77 000 (1.8-fold; p < 0.05). This corresponded with a 1.2-fold reduction in the provision of the first dose of measles vaccine at 6 months compared to 2019. Throughout 2020 there was a 4-fold decline in the number of fully immunized children at 1 year of age (p = 0.84). Emergency room visits fell by 35.7% in 2020 (16 368) compared to 2019 (25 446). Hospital admissions decreased significantly (p < 0.01) in 2020 (9810) compared to 2018 (11 698) and 2019 (10 247). The in-hospital mortality rate increased from 2.3% (96/4163) in 2019 to 3.8% (95/2498) (p < 0.01) in Tygerberg Hospital, where 80% (95/119) of deaths were recorded. Twelve of the 119 (10%) deaths occurred in HIV-positive children (p = <0.01). Measures instituted during the COVID-19 pandemic disrupted access to healthcare services for children. This resulted in an immediate, and potential future, indirect effect on child morbidity and mortality in Cape Town.

Inhaled corticosteroid for patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials.

The efficacy of inhaled corticosteroid (ICS) in the treatment of patients with COVID-19 has been evaluated in randomized controlled trials (RCTs), however, their findings are not consistent. PubMed, Embase, Cochrane Library, ClinicalTrials.gov, Scopus, Web of Science and Google Scholar were searched to June 10, 2023. Only RCTs that investigated the clinical efficacy and safety of ICS for patients with COVID-19 were included. Eleven RCTs were included. ICS users had significantly higher rate of symptom alleviation at day 14 than the control group (risk ratio [RR], 1.13; 95% CI, 1.04-1.23; I2=42%). Additionally, no significant difference between the ICS users and the control group was observed in the composite outcome of urgent care, emergency department (ED) visit or hospitalization (RR, 0.43; 95% CI, 0.08-2.48; I2=85%) and hospitalization or death (RR, 0.85; 95% CI, 0.64-1.12; I2=0%). Finally, ICS user had a non-significantly lower risk of death at day 28 than the control group (0.63% vs 0.99%; RR, 0.82; 95% CI, 0.43-1.56; I2=0%). Additional ICS use, particularly inhaled budesonide may help symptom relief in patients with COVID-19. However, ICS use did not help reduce the risk of urgent care, ED visit, hospitalization, or death.

Patient-Reported Distress and Acute Care Utilization for Cervical Cancer Patients Undergoing Concurrent Chemoradiation

Although concurrent chemo-radiation (CRT) and brachytherapy (BT) is curative for locally advanced cervical cancer (LACC), it requires complex coordination of care and is associated with treatment-related toxicity. Our objective was to evaluate patient-reported symptoms and social distress in LACC patients undergoing concurrent CRT and BT to determine whether they are predictive of unplanned acute care utilization. Patients with LACC treated with concurrent CRT and BT between 2013-2020 completed the Edmonton Symptom Assessment Scale-revised (ESAS-r; 9 cancer-related symptoms ranked 0-10) and the Social Difficulties Inventory-21 (SDI-21; 21 social issues ranked 0-3) at every visit as part of routine distress screening. Acute care utilization was defined as any unplanned visit to the radiation nursing clinic, urgent care clinic, emergency department or hospitalization within 1 year from starting treatment. A logistic regression model will be used to evaluate associations between ESAS-r and SDI-21 scores and acute care utilization. Among 151 LACC patients, a total of 354 ESAS-r and SDI questionnaires were completed longitudinally. Mean age at diagnosis was 49.9 years (30-90), 44% were FIGO 2B and overall treatment time was 53.6 days (32-135). At baseline, the most prevalent moderate to severe symptoms (ESAS-r score ≥4) were well-being (50%), anxiety (44%), tiredness (43%) and pain (36%). Post-treatment, these persisted in 42%, 27%, 38%, and 26%, respectively. The most common social distress at baseline was financial (33%). Financial distress post-treatment was significantly predictive of worse well-being (OR = 5.80, p<0.06), anxiety (OR = 3.33, p<0.04) and depression (OR = 4.76, p<0.01). Use of acute care within 1 year after starting treatment occurred in 103 patients (68%) for a total of 617 visits: radiation nursing clinic 71.3%, urgent care clinic 4.4%, emergency department 8.3%, hospitalization 16%. On average there were 6.6 visits/patient (0-31), with the average number of days between treatment start and first acute care visit being 17.9 (0-74). Cervical cancer patients undergoing concurrent CRT report prevalent financial distress and moderate to severe symptoms that persist post-treatment. Acute care utilization commonly occurred during treatment, highlighting a time when additional support is needed. Predictive modelling for distress factors resulting in acute care utilization is now underway.

Effectiveness of the Original Monovalent Coronavirus Disease 2019 Vaccines in Preventing Emergency Department or Urgent Care Encounters and Hospitalizations Among Adults With Disabilities: VISION Network, June 2021-September 2022

Abstract Adults with disabilities are at increased risk for severe coronavirus disease 2019 (COVID-19). Using data across 9 states during Delta- and Omicron-predominant periods (June 2021–September 2022), we evaluated the effectiveness of the original monovalent COVID-19 messenger RNA vaccines among 521 206 emergency department/urgent care encounters (11 471 [2%] in patients with a documented disability) and 139 548 hospitalizations (16 569 [12%] in patients with a disability) for laboratory-confirmed COVID-19 illness in adults (aged ≥18 years). Across variant periods and for the primary series or booster doses, vaccine effectiveness was similar in those with and those without a disability. These findings highlight the importance of adults with disabilities staying up to date with COVID-19 vaccinations.

Bedside Intestinal Ultrasound Performed in an Inflammatory Bowel Disease Urgent Assessment Clinic Improves Clinical Decision-Making and Resource Utilization.

Patients with inflammatory bowel disease (IBD) require accessible, timely, and noninvasive strategies to monitor disease. The aim was to assess the integration of intestinal ultrasound (IUS) on decision-making and endoscopy utilization in a standardized care pathway. This prospective, multicenter, international, observational cohort study included patients seen within a centralized model for IBD care was conducted during the COVID pandemic. Patients were evaluated with IUS alone or in combination with an in-clinic, unsedated sigmoidoscopy. Demographic, clinical, laboratory, and imaging data, clinical decisions, and need for urgent endoscopy, hospitalization, and surgeries were recorded. Of the 158 patients included, the majority had an established diagnosis of Crohn's disease (n = 123, 78%), and 47% (n = 75) of patients were on biologic therapy. IUS identified active inflammation in 65% (n = 102) of patients, and strictures in 14% (n = 22). Fecal calprotectin levels correlated with inflammation detected on IUS (median of 50 μg/g [Q1-Q3: 26-107 μg/g] without inflammation and 270 μg/g [Q1-Q3: 61-556 μg/g] with inflammation; p = 0.0271). In the majority of patients, clinical assessment with IUS led to an acute change in IBD-specific medications (57%, n = 90) and avoided or delayed the need for urgent endoscopy (85%, n = 134). Four patients were referred for urgent surgical consultation. Point-of-care IUS used in a flare clinic pathway is a useful strategy to improve effective IBD care delivery and to assist in therapeutic management decisions, in many cases avoiding the acute need for endoscopy.

Telemedicine Consultations for Children With Musculoskeletal Injuries: Data from the Turner National Medical Research Center of Сhildren’s Orthopedics and Trauma Surgery

Background. Currently, the mortality rate of pediatric patients due to injuries surpasses mortality from other causes worldwide. The selection and timely transfer of the injured to specialized clinics are crucial elements of the healthcare system. Telemedicine consultations (TMC) are considered by several authors as an effective means to enhance the quality of trauma care and optimize patient routing processes.&#x0D; Aim of the study was to analyze the results of urgent and emergent telemedicine consultations and hospitalizations based on telemedicine consultations for children with musculoskeletal injuries.&#x0D; Methods. TMC requests from 2020 to 2022 were analyzed. When evaluating TMC requests, attention was given to the type of request (planned, urgent, emergent), the region from which the request originated, and the correspondence of the requests urgency category to the patients diagnosis. The study also involved an analysis of the injury structure, its severity according to the Injury Severity Score (ISS) at the time of trauma, and the timelines for requesting and transferring to the federal clinic from the moment of injury.&#x0D; Results. From 2020 to 2022, a total of 3745 requests for TMC were received. Among them, there were 572 urgent and emergent requests. A threefold increase in the number of TMC requests was observed over the span of three years. In the same period, 78 patients were transferred to the clinic. For 36 patients with combined and multiple injuries, the severity of trauma was assessed using the ISS scale. The average score was 31 (min 9; max 57). The average time for regional institutions to send a request from the moment of the patients hospitalization was 6.7 days. Hospitalization in the centers clinic from the moment of injury was 10.3 days (min 1; max 58).&#x0D; Conclusion. The study revealed the following issues that need to be addressed through further organizational steps: a high percentage of mismatch between the type of request and the actual clinical picture, delayed consultations, prolonged medical evacuation, and organizational aspects of medical evacuation.

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

BackgroundAmbulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify...

Regional variations in short stay urgent paediatric hospital admissions: a sequential mixed-methods approach exploring differences through data linkage and qualitative interviews

ObjectivesThe aim of this sequential mixed-methods study was to describe and understand how paediatric short stay admission (SSA) rates vary across Health Board regions of Scotland.DesignExploratory sequential mixed-methods study. Routinely...

Participant Satisfaction of a Community-based Telehealth Clinic for Atopic Dermatitis.

Atopic dermatitis (AD), a chronic, relapsing inflammatory disease that affects more than 30 million children and adults in the US, disproportionally impacts African American (AA) and Hispanic children, with a higher prevalence of severe AD in these populations than in white children.1,2 Visits to urgent care, emergency departments, and hospitalizations for AD in the United States were more common among AA and Hispanic adults, and those with lower socioeconomic status.1,3 In Washington DC, outcomes and access to care among the District's poor and underrepresented minorities lag far behind other groups. Ward 8, for example, which is 89% Black, has the District's highest per capita rate of coronavirus-related deaths - 6 for every 10,000 residents.4 These disparities have been long-lived and pervasive in all areas of medicine, including dermatology.5.