Vulnerable Group Of Patients Research Articles

ANALYSIS OF PATIENTS - CHILDREN WHO PASSED THROUGH THE EMERGENCY DEPARTMENT OF ST. MARINA UNIVERSITY HOSPITAL - VARNA FOR A PERIOD OF SEVEN YEARS

Emergency medicine is a dynamically complex and well-coordinated specialty. However, paediatric emergency sub-specialty is not yet well developed in most low and middle income countries. The purpose of the present study is to analyze the pediatric patients who passed through the emergency department of the hospital. Results: Total examined children - 44547. Hospitalized – 12 062 - 30.7% of the total. Boys predominate (54.0%). Children in the age group 1-10 years - 81.8%. The patient flow in the pediatric emergency department from other districts increased by 35.8%. Conclusion: Children are a particularly vulnerable group of patients who go through the emergency department, which is related to the specifics of pediatric care. The results of the study show that the largest proportion of pediatric patients are children aged 1-10 years, males, who sought medical help in connection with respiratory infections.

Advances of Recombinant Adenoviral Vectors in Preclinical and Clinical Applications.

Adenoviruses (Ad) have the potential to induce severe infections in vulnerable patient groups. Therefore, understanding Ad biology and antiviral processes is important to comprehend the signaling cascades during an infection and to initiate appropriate diagnostic and therapeutic interventions. In addition, Ad vector-based vaccines have revealed significant potential in generating robust immune protection and recombinant Ad vectors facilitate efficient gene transfer to treat genetic diseases and are used as oncolytic viruses to treat cancer. Continuous improvements in gene delivery capacity, coupled with advancements in production methods, have enabled widespread application in cancer therapy, vaccine development, and gene therapy on a large scale. This review provides a comprehensive overview of the virus biology, and several aspects of recombinant Ad vectors, as well as the development of Ad vector, are discussed. Moreover, we focus on those Ads that were used in preclinical and clinical applications including regenerative medicine, vaccine development, genome engineering, treatment of genetic diseases, and virotherapy in tumor treatment.

The impact of a multidisciplinary approach on elderly patients hospitalized with SARS-CoV-2

Abstract BACKGROUND. The COVID-19 pandemic had a devastating impact in terms of both somatic and mental morbidity. The most vulnerable group of patients is represented by the elderly, due to their global fragility. During the COVID-19 pandemic, research have stated that age and related comorbidities are associated with the outcome and evolution of the coronavirus infection. MATERIAL AND METHODS. We performed a prospective observational study by applying a specific unsystematized questionnaire containing 21 questions, including patients admitted between 01.10.2021-16.03.2022 in the Internal Medicine Clinic and the Infectious Diseases Clinic COVID-19. Two hundred patients were included in the study of which the most important group was represented by the elderly. The current study aimed to demonstrate the clinical complexity of the patients hospitalized with SARS-CoV-2 and the importance of a multidisciplinary approach. RESULTS. Among those patients who complained of cardiovascular symptoms such as tachycardia, palpitations, chest pains, 59.6% had no cardiac pathology, therefore they required psychiatric examination and specific anxiolytic and/or antidepressant treatment. Despite the fact that alarmingly low rates of vaccination were observed, we noticed a statistically significant association between the presence of insomnia and vaccination status: half of the vaccinated stated that they sleep as well as usual, compared to only 22.8% of the unvaccinated. We also found a statistically significant association between the presence of insomnia and peripheric oxygen saturations below 93%. CONCLUSION. The results of our study highlight the importance of a multidisciplinary management of the SARS-CoV-2 infection, especially targeting the elderly and fragile patients.

Pan-Indian Clinical Registry of Invasive Fungal Infections Among Patients in the Intensive Care Unit: Protocol for a Multicentric Prospective Study.

Fungal infections are now a great public health threat, especially in those with underlying risk factors such as neutropenia, diabetes, high-dose steroid treatment, cancer chemotherapy, prolonged intensive care unit stay, and so on, which can lead to mycoses with higher mortality rates. The rates of these infections have been steadily increasing over the past 2 decades due to the increasing population of patients who are immunocompromised. However, the data regarding the exact burden of such infection are still not available from India. Therefore, this registry was initiated to collate systematic data on invasive fungal infections (IFIs) across the country. The primary aim of this study is to create a multicenter digital clinical registry and monitor trends of IFIs and emerging fungal diseases, as well as early signals of any potential fungal outbreak in any region. The registry will also capture information on the antifungal resistance patterns and the contribution of fungal infections on overall morbidity and inpatient mortality across various conditions. This multicenter, prospective, noninterventional observational study will be conducted by the Indian Council of Medical Research through a web-based data collection method from 8 Advanced Mycology Diagnostic and Research Centers across the country. Data on age, gender, clinical signs and symptoms, date of admission, date of discharge or death, diagnostic tests performed, identified pathogen details, antifungal susceptibility testing, outcome, and so on will be obtained from hospital records. Descriptive and multivariate statistical methods will be applied to investigate clinical manifestations, risk variables, and treatment outcomes. These Advanced Mycology Diagnostic and Research Centers are expected to find the hidden cases of fungal infections in the intensive care unit setting. The study will facilitate the enhancement of the precision of fungal infection diagnosis and prompt treatment modalities in response to antifungal drug sensitivity tests. This registry will improve our understanding of IFIs, support evidence-based clinical decision-making ability, and encourage public health policies and actions. Fungal diseases are a neglected public health problem. Fewer diagnostic facilities, scanty published data, and increased vulnerable patient groups make the situation worse. This is the first systematic clinical registry of IFIs in India. Data generated from this registry will increase our understanding related to the diagnosis, treatment, and prevention of fungal diseases in India by addressing pertinent gaps in mycology. This initiative will ensure a visible impact on public health in the country. DERR1-10.2196/54672.

A114 IMPROVING THE QUALITY OF PARACENTESIS PRACTICES IN PEOPLE WITH ADVANCED CIRRHOSIS IN AN AMBULATORY CARE SETTING

Abstract Background Spontaneous bacterial peritonitis (SBP) is a lethal complication of decompensated cirrhosis carrying a 90% mortality rate when left untreated. Despite AASLD recommendations, there is a practice gap regarding fluid cell count (FCC) collection during paracentesis. Aims We initiated prospective quality improvement (QI) project to improve FCC collection in an ambulatory care setting from a baseline of 78% to a goal of 100% compliance between September 11, 2022 and April 17, 2023. Methods We examined the effects of a quality improvement initiative in 233 adult patient encounters with cirrhosis undergoing paracentesis in an ambulatory setting located within a quaternary care centre in Toronto, Canada within the study timeframe. Using a multidisciplinary approach, the quality improvement initiatives included focused groups, education regarding AASLD guidelines, development of a paracentesis bundle, and streamlining workflow process. Descriptive statistics were collected. Statistical analysis using run charts and p-charts were conducted using QI Macros. Approval was obtained from the QI Review Committee at the institution where this QI initiative took place. Results Baseline adherence for collecting ascitic FCC per paracentesis procedure was 78%. Inconsistencies during process mapping such as variations in documentation, printing FCC labels and consistency in FCC collection were identified as root causes. Thus, bedside paracentesis bundles were introduced to standardize process and improve workflow. Post-intervention, the FCC rate increased marginally to 79.6% with no special cause variation identified (Figure 1). Subgroup analysis demonstrated FCC collection rates of 100% amongst registered nurse (RN) and nurse practitioners (NP), 97% amongst resident physicians, and 92% amongst attending physicians. Subsequently, another subgroup analysis was completed demonstrating 97% FCC collection rate amongst general hepatology group, while 40% FCC rate amongst specialty hepatology group. Overall rate of SBP was 1.62% (N=3). Conclusions This prospective QI study revealed a gap in guidance pertaining to the role of ascitic fluid cell count collection in patients with cirrhosis undergoing paracentesis in ambulatory settings. Further studies ascertaining rationale for not sending FCC may be helpful in elucidating why there is a gap in clinical practice. Additionally conducting studies in ambulatory settings to assess FCC collection's impact on morbidity and mortality will provide vital evidence and clarity for the role of FCC in this vulnerable patient group. Figure 1: P-chart demonstrating percentage FCC Collection per week from September 11, 2022 to April 17, 2023. UCL indicates upper control limit; CL, center line; LCL, lower Control Limit. Funding Agencies Toronto Centre for Liver Disease funded the MSc QI program for Mary Sedarous (writer) who completed this study as her MSc QI project.

SARS-CoV-2 Infection and Multiple Sclerosis: Proactive Approach in a Vulnerable Patient Group through Daily Vitamin D Supplementation?

SARS-CoV-2 Infection and Multiple Sclerosis: Proactive Approach in a Vulnerable Patient Group through Daily Vitamin D Supplementation?

Physical Activity Intervention for Urban Black Women With Asthma: Protocol for a Randomized Controlled Efficacy Study.

Black women experience a higher prevalence of poor asthma outcomes and physical inactivity than their White counterparts. Black women comprise a particularly vulnerable group of patients with asthma, with some of the highest rates of asthma in adults, high health care use (emergency department visits and hospitalizations), and the highest crude asthma mortality rate of all race or ethnicity groups. Despite recommendations to engage in regular physical activity, fewer than 15% of Black women meet the 2008 National Physical Activity Guidelines, the lowest of all racial subgroups of adults. Given the connection between physical inactivity and poor asthma outcomes, addressing physical activity among Black women with asthma is imperative. This 2-arm randomized controlled trial aims to (1) determine the efficacy of a lifestyle walking intervention on asthma control compared to an education (control) group over 24 weeks, (2) examine the maintenance effects of the lifestyle walking intervention on asthma control at 48 weeks, (3) explore the behavioral mediators (eg, self-efficacy, social support, self-regulation, and daily physical activity levels) and contextual moderators (eg, baseline asthma severity, neighborhood environment, comorbid conditions, and social determinants of health) that contribute to treatment responsiveness, and (4) assess the reach and implementation potential of the intervention. The proposed study (ACTION [A Lifestyle Physical Activity Intervention for Minority Women with Asthma]) delivers a 24-week lifestyle walking intervention designed for and by urban Black women with asthma. Participants (n=224) will be recruited through 2 urban health care systems that care for a diverse Black population. Patients will be randomized to one of two groups: (1) ACTION intervention (group sessions, physical activity self-monitoring-Fitbit, and text-based support for step goal setting) or (2) education control (an individual asthma education session and SMS text messages related to asthma education). Outcome assessments will take place at baseline, 12, 24, and 48 weeks. The primary outcome is a change in asthma control from baseline to week 24 as assessed by the asthma control questionnaire-6 (ACQ-6). Secondary outcomes include asthma-related quality of life, health care use, and asthma exacerbations and behavioral outcomes such as self-efficacy, self-regulation, social support, and physical activity. This study was funded by the National Institute of Minority Health Disparities in August 2022. We pilot-tested our recruitment and intervention procedures and began recruitment in April 2023, with the enrollment of our first participant in May 2023. The anticipated completion of the study is April 2027. This study will deliver a new approach to physical activity interventions in Black women with asthma and help to provide guidance for addressing physical activity within this subgroup. This study will also provide a potential framework for future studies in minoritized populations with other disease conditions associated with low levels of physical activity. ClinicalTrials.gov NCT05726487; https://clinicaltrials.gov/study/NCT05726487. DERR1-10.2196/55700.

Brain Tumor Imaging without Gadolinium-based Contrast Agents: Feasible or Fantasy?

Gadolinium-based contrast agents (GBCAs) form the cornerstone of current primary brain tumor MRI protocols at all stages of the patient journey. Though an imperfect measure of tumor grade, GBCAs are repeatedly used for diagnosis and monitoring. In practice, however, radiologists will encounter situations where GBCA injection is not needed or of doubtful benefit. Reducing GBCA administration could improve the patient burden of (repeated) imaging (especially in vulnerable patient groups, such as children), minimize risks of putative side effects, and benefit costs, logistics, and the environmental footprint. On the basis of the current literature, imaging strategies to reduce GBCA exposure for pediatric and adult patients with primary brain tumors will be reviewed. Early postoperative MRI and fixed-interval imaging of gliomas are examples of GBCA exposure with uncertain survival benefits. Half-dose GBCAs for gliomas and T2-weighted imaging alone for meningiomas are among options to reduce GBCA use. While most imaging guidelines recommend using GBCAs at all stages of diagnosis and treatment, non-contrast-enhanced sequences, such as the arterial spin labeling, have shown a great potential. Artificial intelligence methods to generate synthetic postcontrast images from decreased-dose or non-GBCA scans have shown promise to replace GBCA-dependent approaches. This review is focused on pediatric and adult gliomas and meningiomas. Special attention is paid to the quality and real-life applicability of the reviewed literature.

Osteoporotic vertebral fractures of the thoracic and lumbar spine

The frequency of osteoporotic vertebral fractures in the clinical routine is increasing due to the demographic change. They are the most frequent fractures associated with osteoporosis and affect an especially morbid and vulnerable group of patients. These fractures often occur after minor trauma or spontaneously. Pain is the predominant symptom, whereas mechanical stability is mostly sufficient, in comparison to vertebral fractures after high-energy trauma, and is not a predominant indication for surgery. These fractures can be described using the classification for fractures associated with osteoporosis and the corresponding treatment recommendations are guided by them. Besides the specific treatment of osteoporotic vertebral fractures, a holistic treatment of patients taking pre-existing comorbidities into consideration is decisive. A mobilization as quickly as possible and treatment of the underlying osteoporosis are important to prevent further fractures.

CLINICAL, BIOCHEMICAL, AND INTESTINAL ULTRASONOGRAPHY RESPONSE TO CURCUMIN-QINGDAI (CURQD) COMBINATION IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE SERIES

Abstract BACKGROUND There are few FDA-approved therapies for pediatric patients with inflammatory bowel disease (IBD). Clinical remission rates plateau at 60%, even with the currently available biologic therapies. Nutraceuticals are novel alternative treatments that can be used as adjunct treatments. AIM In this case series of 8 patients, we aim to present the clinical and radiological response to a novel nutraceutical agent, CurQD, composed of QingDai (Indigo Naturalis) and Curcumin. METHODS Patients included required a baseline pre-treatment clinical assessment and at least a single follow-up examination. Clinical status was evaluated based on the Physician General Assessment (PGA, determined independently from the clinical scoring systems) and the pediatric Crohn’s disease activity index (PCDAI) or the pediatric ulcerative colitis activity index (PUCAI), as appropriate. Baseline biomarkers (Hgb, ESR, CRP, albumin, and calprotectin(FC)) were collected pre and post-treatment when available. When available, intestinal ultrasound (IUS) features were also noted. On the IUS, bowel wall thickness (BWT, in mm) and color Doppler signaling (measured by the modified Limberg score graded 0,1,2, or 3 based on severity) were collected. The longitudinal changes were demonstrated on the most inflamed segment. Considering the small sample size, only descriptive statistics were applied. RESULTS Primary therapies received included anti-TNFα for 3 patients, ustekinumab in 3 patients, 1 on vedolizumab, and mesalamine in 1. Baseline assessment was done at a median time of 1.8 weeks (IQR 0.9-3.6 weeks) before starting the supplement, and the follow-up was 3.9 weeks (IQR 2.8-5.4 weeks) after starting the supplement. Two patients were in clinical remission at baseline but had active disease based on Doppler activity on IUS, 3 patients had mild active disease, and 3 patients had either moderate or severe disease activity. At follow-up, all patients but one were in clinical remission. (Table 1) Median baseline FC decreased from 1047.4 ug/g (IQR 532.4-1107) to 27.1 (IQR 27.5-341.3). Five patients had complete IUS information. When isolating the most inflamed segment on IUS, all patients demonstrated a response to treatment, noted by a decrease in BWT and/or a decrease in Doppler signaling. (Figure 1) No patient had a baseline therapy change after their follow-up. One patient reported abdominal bloating after starting CurQD and discontinued the product after five weeks. CONCLUSION CurQD is a promising nutraceutical that may assist in breaking the therapeutic ceiling of biological therapies in IBD. Based on this small experience, a larger randomized controlled trial in children would be needed to assess the safety and efficacy of this product in this vulnerable patient group. Furthermore, IUS is a practical tool for evaluating response to therapy in a pragmatic clinical setting. Table 1 Change in clinical disease scores in patients receiving CurQD Figure 1 Description of changes in a) bowel wall thickness (BWT) and b) color Doppler signaling (measured by the modified Limberg score) in patients treated with CurQD.

Quality of life and healthcare utilization during the COVID-19 pandemic are more restricted in chronically ill than in healthy children: a tertiary care children’s hospital experience

The global COVID-19 pandemic forced changes in everyday life of children and adolescents due to government containment measures, an altered healthcare accessibility and utilization, and public concern about SARS-CoV-2 transmission. Data on the challenges and impact on children and their families with chronic diseases are limited. The primary objectives of this study were to assess (i) concerns for SARS-CoV-2 infection, (ii) perceived effects on health-related and overall quality of life (HRQoL and QoL), and (iii) accessibility and utilization of healthcare, comparing families with chronically ill children to families with healthy children during the second SARS-CoV-2 infection wave in Germany. A caregiver questionnaire was designed and participation offered in the emergency department and outpatient clinic of a German tertiary care children’s hospital. 45.9% of the 205 participants were majorly concerned about their children contracting a SARS-CoV-2 infection. Caregivers of chronically ill children (128/205, 62.4%) stated significantly more often a negative impact on their child’s QoL (w = 0.17; p = 0.014), while caregivers of chronically ill adolescents over the age of 13 expressed significantly more frequent a negative impact on their child’s HRQoL (w = 0.21; p = 0.016). Outpatient appointments for chronically ill children were significantly more often canceled (w = 0.17; p = 0.025). Caregivers of chronically ill children were significantly more likely to report that they would actively delay hospital visits for emerging health issues due to the pandemic (w = 0.12; p = 0.049). Conclusion: Our findings underscore the importance of identifying families with chronically ill children as a vulnerable patient group with higher burdens during the COVID-19 pandemic and potential future pandemics. Healthcare providers may mitigate such burdens by ensuring reliable appointment allocation, offering contactless healthcare options, and providing tailored advice regarding vulnerabilities and preventive measures specific to their chronically ill children.What is Known:• The SARS-CoV-2 pandemic has led to significant restrictions in everyday life and both accessibility and utilization of healthcare for children and adolescents.• Chronically ill children faced exceptional challenges as they depend on regular and functioning medical care, but data comparing the pandemic’s impact between chronically ill and healthy children are lacking.What is New:• The perceived impact of the SARS-CoV-2 pandemic on quality of life is more negative for chronically ill children and their health-related quality of life is more often affected compared to healthy children.• Caregivers of chronically ill children would more often delay a visit to their child’s doctor during the SARS-CoV-2 pandemic and their medical appointments are more often postponed which both could increase health burdens for such vulnerable patients.

2015 Identifying and Managing Visual Impairment in Older Patients with Falls on a Care of the Elderly (COTE) ward

Abstract Introduction In 2019, the Royal College of Physicians (RCP) advised that all patients should have their vision screened if identified as a falls risk. Our aim was to implement a bedside visual screening test and establish an onward inpatient referral to Hospital Eye Services (HES). Method This is a collaborative Quality Improvement project involving Geriatric Medicine, HES and the Royal National Institute of Blind People (RNIB). A pilot study cross referenced falls admissions with previous known ophthalmic data to estimate the proportion of known vision loss in this group. In the second phase of the project, a bedside visual screening test has been introduced for all patients admitted to COTE with a fall. Patients failing the screening are reviewed by an RNIB Eye Clinic Liaison Officer (ECLO) and if necessary, a prompt inpatient HES review is arranged. Results Of 182 patients admitted following a fall, in the pilot study, 112 (61%) were known to ophthalmology previously. Of patients known to ophthalmology, 28 (25%) had vision of 6/18 or worse and would be considered to struggle with daily living tasks. 12 (10%) had a certificate of visual impairment (CVI) and 3 (3%) were eligible for CVI but had not been previously registered. One year following implementation of bedside vision testing, 287 patients had been reviewed after failing bedside screening. 97 of these had an onward referral sent or an intervention performed. The first ‘COTE ECLO’ post has been funded as a result of this work. Conclusion Assessing vision is a critical element of the assessment of patients with falls. Through collaboration with the RNIB and Ophthalmology a successful pathway has been developed to address visual impairment in this vulnerable group of patients.

Capacity to consent to treatment in severe eating disorders

Eating disorders represent a disabling, deadly and costly condition, whose principal treatment is constituted by weigh restoration and psychotherapy. Partial or total refuse of treatment is very common, leading some authors to question their decision-making capacity (DMC) to consent to treatment. However, very few studies have investigated treatment DMC, leading to contrasting results. Forty-five women were enrolled at the Psychiatric and Eating Disorders Unit of the University Hospital Policlinico Umberto I of Rome. Psychiatric symptoms severity (Brief Psychiatric Rating Scale Expanded, BPRS-E), treatment DMC (MacArthur Competence Assessment Tool for Treatment, MacCAT-T), depressive symptoms (Hamilton Depression Rating Scale, HAM-D), anxiety symptoms (Hamilton Anxiety Rating Scale, HAM-A), symptoms and psychological characteristics of eating disorders (Eating Disorder Inventory, EDI-3) and Metacognitive beliefs (Metacognitions Questionnaire 30, MCQ-30) were assessed. Sixty-seven percent of the total sample showed low treatment DMC; specifically, 70.4% of patients affected by Anorexia Nervosa, 72.7% of patients affected by Bulimia Nervosa, and 42.9% of patients affected by Binge Eating Disorder. Specific psychopathological symptoms enhance or hamper patients’ decisional capacities. Clinicians should be aware of the risk of impaired DMC in this vulnerable group of patients and pay attention at those factors suggesting the need of an in-depth evaluation.

Incidence and Severity of COVID-19 in Relation to Anti-Receptor-Binding Domain IgG Antibody Level after COVID-19 Vaccination in Kidney Transplant Recipients.

Kidney transplant recipients (KTRs) elicit an impaired immune response after COVID-19 vaccination; however, the exact clinical impact remains unclear. We therefore analyse the relationship between antibody levels after vaccination and the risk of COVID-19 in a large cohort of KTRs. All KTRs living in the Netherlands were invited to send a blood sample 28 days after their second COVID-19 vaccination for measurement of their IgG antibodies against the receptor-binding domain of the SARS-CoV-2 spike protein (anti-RBD IgG). Information on COVID-19 was collected from the moment the blood sample was obtained until 6 months thereafter. Multivariable Cox and logistic regression analyses were performed to analyse which factors affected the occurrence and severity (i.e., hospitalization and/or death) of COVID-19. In total, 12,159 KTRs were approached, of whom 2885 were included in the analyses. Among those, 1578 (54.7%) became seropositive (i.e., anti-RBD IgG level >50 BAU/mL). Seropositivity was associated with a lower risk for COVID-19, also after adjusting for multiple confounders, including socio-economic status and adherence to COVID-19 restrictions (HR 0.37 (0.19-0.47), p = 0.005). When studied on a continuous scale, we observed a log-linear relationship between antibody level and the risk for COVID-19 (HR 0.52 (0.31-0.89), p = 0.02). Similar results were found for COVID-19 severity. In conclusion, antibody level after COVID-19 vaccination is associated in a log-linear manner with the occurrence and severity of COVID-19 in KTRs. This implies that if future vaccinations are indicated, the aim should be to reach for as high an antibody level as possible and not only seropositivity to protect this vulnerable patient group from disease.

The development of type 2 diabetes management in people with severe mental illness in the Capital Region of Denmark from 2001 to 2015.

Type 2 diabetes (T2D) treatment has changed markedly within the last decades. We aimed to explore whether people with severe mental illness (SMI) have followed the same changes in T2D treatment as those without SMI, as multiple studies suggest that people with SMI receive suboptimal care for somatic disorders. In this registry-based annual cohort study, we explored the T2D treatment from 2001 to 2015 provided in general practices of the Greater Copenhagen area. We stratified the T2D cohorts by their pre-existing SMI status. T2D was defined based on elevated glycated hemoglobin (≥48 mmol/mol) or glucose (≥11 mmol/L) using data from the Copenhagen Primary Care Laboratory Database. Individuals with schizophrenia spectrum disorders (ICD-10 F20-29) or affective disorders (bipolar disorder or unipolar depression, ICD-10 F30-33) were identified based on hospital-acquired diagnoses made within 5 years before January 1 each year for people with prevalent T2D or 5 years before meeting our T2D definition for incident patients. For comparison, we defined a non-SMI group, including people who did not have a hospital-acquired diagnosis of schizophrenia spectrum disorders, affective disorders, or personality disorders. For each calendar year, we assembled cohorts of people with T2D with or without SMI. We used Poisson regression to calculate the rates per 100 person-years of having at least one biochemical test (glycated hemoglobin, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and urine albumin-creatinine ratio), having poor control of these biochemical results, taking glucose-lowering or cardiovascular medications, or experiencing a clinical outcome, including all-cause mortality and cardiovascular mortality. Three outcomes (cardiovascular events, cardiovascular mortality, and all-cause mortality) were additionally examined and adjusted for age and sex in a post hoc analysis. From 2001 to 2015, 66,914 individuals were identified as having T2D. In 2015, 1.5% of the study population had schizophrenia spectrum disorder and 1.4% had an affective disorder. The number of people who used biochemical tests or had poor biochemical risk factor control was essentially unrelated to SMI status. One exception was that fewer LDL cholesterol tests were done on people with affective disorders and schizophrenia spectrum disorders at the beginning of the study period compared to people in the non-SMI group. This difference gradually diminished and was almost nonexistent by 2011. There was also a slightly slower rise in UACR test rates in the SMI groups compared to other people with T2D during the period. Throughout the study period, all groups changed their use of medications in similar ways: more metformin, less sulfonylurea, more lipid-lowering drugs, and more ACEi/ARBs. However, people with schizophrenia disorder consistently used fewer cardiovascular medications. Cardiovascular events were more common in the affective disorder group compared to the non-SMI group from 2009 to 2015 (rate ratio 2015 : 1.36 [95% CI 1.18-1.57]). After adjustment for age and sex, all-cause mortality was significantly higher among people with a schizophrenia spectrum disorder each year from 2003 to 2015 compared to the non-SMI group (rate ratio 2015 : 1.99 [95% CI 1.26-3.12]). Persons with schizophrenia or affective disorders demonstrated the same treatment changes for T2D as those without SMI in general practice. The lower use of most types of cardiovascular medications among people with schizophrenia disorders indicates potential undertreatment of hypertension and dyslipidemia and remains throughout the study period. Cardiovascular events were most common among people with affective disorders, but this was not reflected in a higher proportion using cardiovascular preventive medications. This knowledge should be considered in the management of this vulnerable patient group.

Hospitalisation patterns in interstitial lung diseases: data from the EXCITING-ILD registry

BackgroundInterstitial lung diseases (ILD) comprise a heterogeneous group of mainly chronic lung diseases with more than 200 entities and relevant differences in disease course and prognosis. Little data is available on hospitalisation patterns in ILD.MethodsThe EXCITING-ILD (Exploring Clinical and Epidemiological Characteristics of Interstitial Lung Diseases) registry was analysed for hospitalisations. Reasons for hospitalisation were classified as all cause, ILD-related and respiratory hospitalisations, and patients were analysed for frequency of hospitalisations, time to first non-elective hospitalisation, mortality and progression-free survival. Additionally, the risk for hospitalisation according to GAP index and ILD subtype was calculated by Cox proportional-hazard models as well as influencing factors on prediction of hospitalisation by logistic regression with forward selection.ResultsIn total, 601 patients were included. 1210 hospitalisations were recorded during the 6 months prior to registry inclusion until the last study visit. 800 (66.1%) were ILD-related, 59.3% of admissions were registered in the first year after inclusion. Mortality was associated with all cause, ILD-related and respiratory-related hospitalisation. Risk factors for hospitalisation were advanced disease (GAP Index stages II and III) and CTD (connective tissue disease)-ILDs. All cause hospitalisations were associated with pulmonary hypertension (OR 2.53, p = 0.005). ILD-related hospitalisations were associated with unclassifiable ILD and concomitant emphysema (OR = 2.133, p = 0.001) as well as with other granulomatous ILDs and a positive smoking status (OR = 3.082, p = 0.005).ConclusionOur results represent a crucial contribution in understanding predisposing factors for hospitalisation in ILD and its major impact on mortality. Further studies to characterize the most vulnerable patient group as well as approaches to prevent hospitalisations are warranted.

Risk Profiles and Treatment Patterns in Atrial Fibrillation Patients with Chronic Kidney Disease Receiving or not Receiving Anticoagulation Therapy.

Background Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are at high risk for both thromboembolism and bleeding events. The latter induces a potential reason for withholding oral anticoagulation (OAC) despite an indication for prophylaxis of thromboembolic events. Methods AF patients with CKD (estimated glomerular filtration [eGFR] rate between 15 and 49 mL/min per 1.73 m 2 ) were included in a prospective international registry in Europe between 2016 and 2020, that is, XARENO (factor XA inhibition in renal patients with nonvalvular atrial fibrillation observational registry). The study enrolled adult patients treated at the discretion of physicians with rivaroxaban, vitamin K antagonists (VKA), or without OAC (w/oOAC). Here, we report a prespecified explorative baseline comparison between patients receiving OAC or no OAC within XARENO. Results In total, 1,544 patients (mean age: 78.2 years, mean eGFR: 36.2 mL/min) were studied (rivaroxaban n = 764, VKA n = 691, w/oOAC n = 89). Patients in the w/oOAC group were older and had a similar stroke (mean CHA 2 DS 2 -VASc score 4.0) but higher bleeding risk (mean modified Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score 2.5 vs. 1.8) compared with the OAC groups. The distribution of comorbidities including hypertension, diabetes, and heart failure was similar. Treatment with antiplatelet drugs was fivefold more frequent in the w/oOAC group. Conclusion Only 5.8% of the overall population of AF patients with advanced CKD received no OAC. These patients were older and had a higher bleeding risk, which might explain this decision, but which contrasts with the more frequent use of antiplatelet drugs in this vulnerable group of patients.

Advancing equity in challenging times: A qualitative study of telehealth expansion and changing patient-provider relationships in primary care settings during the COVID-19 pandemic.

The patient-provider relationship is critical for achieving high-quality care and better health outcomes. During the COVID-19 pandemic, primary care practices rapidly transitioned to telehealth. While telehealth provided critical access to services for many, not all patients could optimally utilize it, raising concerns about its potential to exacerbate inequities in patient-provider relationships. We investigated technical and workforce-related barriers to accessing telehealth and the impacts on patient-provider relationships for vulnerable populations. Qualitative, semi-structured interviews from May 2021 to August 2021 with 31 individuals (medical directors, physicians, and medical assistants) working at 20 primary care practices in Massachusetts, North Carolina, and Texas. Thematic analysis to better understand how barriers to using telehealth complicated patient-provider relationships. Interviewees shared challenges for providers and patients that had a negative effect on patient-provider relationships, particularly for vulnerable patients, including older adults, lower socio-economic status patients, and those with limited English proficiency. Providers faced logistical challenges and disruptions in team-based care, reducing care coordination. Patients experienced technological challenges that made accessing and engaging in telehealth difficult. Interviewees shared challenges for patient-provider relationships as commonly used telephone-only telehealth reduced channels for non-verbal communication. This study indicates that barriers to virtual interaction with patients compared to in-person care likely led to weaker personal relationships that may have longer-term effects on engagement with and trust in the healthcare system, particularly among vulnerable patient groups. Additional support and resources should be available to primary care providers to optimize telehealth utilization.

Retrospective cross-sectional analysis of concurrent VTE diagnosis in hospitalised socially excluded individuals in Ireland

ObjectiveSocial exclusion (such as that experienced by people who are homeless, incarcerated or use drugs) increases morbidity across a range of diseases but is poorly captured in routine data sets....

Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study

ObjectivesLittle is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial...