Vulnerable Patient Population Research Articles

Using consumer wearables to estimate physical activity of nursing home residents with dementia

Aim: Physical activity of nursing home residents can be assessed with tools such as questionnaires and standardized fitness tests. For residents with dementia, however, those tools can be cognitively challenging and difficult to administer. Consumer wearables could potentially aid as an affordable tool for ubiquitous assessment. Methods: In this pilot study with 16 participants, we explored how measurements with an off-the-shelf wearable relate to structured observations of physical activity. We collected both processed and raw tri-axial accelerometer data from Samsung wrist-worn fitness trackers. To anchor those data in the free-living environment, we compared the measurements with the physical activity scale of the Medlo behavioral observation scheme. Results: We showed that consumer wearables are a valid tool for long-term data collection in this vulnerable patient population. Conclusions: Regarding the movement intensity, the data collected by fitness trackers is overall in accordance with the data collected with the observational tool. Regarding the type of movement, we concluded that the automatic activity classification on the wearables is not yet ready for use with a mostly sedentary patient population.

Classification, Importance, and Pathogenicity of Facklamia Species and Related Bacteria

Facklamia is a genus of Gram-positive, facultatively anaerobic cocci, first identified in 1997. These bacteria are part of the family Aerococcaceae, closely related to other lactic acid bacteria in the order Lactobacillales. The genus currently includes species like Facklamia hominis, Facklamia ignava, and Facklamia languida, which are often found in human clinical samples including blood, cerebrospinal fluid, and wounds. While typically harmless in healthy individuals, Facklamia infections can lead to serious complications in immunocompromised patients or those with underlying conditions and are implicated in infections such as bacteremia, paendocarditis, and chorioamnionitis. The recognition of Facklamia in clinical settings has grown, necessitating more research into their epidemiology and significance. Facklamia species are catalase-negative and typically form small chains or clusters. Accurate identification of these bacteria is critical due to their close resemblance to other cocci, such as Streptococci, under a microscope. The pathogenic mechanisms of Facklamia are not fully understood, but they are increasingly associated with nosocomial infections, particularly in vulnerable patient populations. Accurate diagnostic methods and awareness of Facklamia's pathogenic potential are critical for effective treatment.

Feasibility and efficacy of home-based lymphedema exercises for head and neck cancer patients at a safety net hospital.

Lymphedema therapy is an effective tool in mitigating head and neck lymphedema morbidity and long-term fibrosis. Studies have shown the efficacy of facility-based therapy; however, access can be limited by sociodemographic factors, including socioeconomic status and transportation. This study evaluates the feasibility and effectiveness of home-based lymphedema therapy in a socially vulnerable patient population. A retrospective chart review analyzed patients who underwent home-based lymphedema exercise regimen after training with a lymphedema-trained speech language pathologist between 2019 and 2022 at a tertiary academic medical center. Patient and cancer demographics were collected. Primary outcomes measured were quality of life surveys and diet status. Of the 27 patients included, 85.1% were in the two highest quintiles of neighborhood deprivation based on national Area Deprivation Index (ADI). Treatment breakdown included 78% who were treated with surgery, 96% completed radiation and 59.3% chemotherapy. Six months after initiating lymphedema therapy, most patients (59.3%) were compliant with exercises. Quality of life scores showed trends toward improvement, but only a decrease in condition-related anxiety at 3months (p=0.004) reached statistical significance. Improvement in diet was significant at 6 and 9months after initiation of treatment (p=0.020). Patient compliance rate demonstrates feasibility of home exercises for lymphedema treatment in a tertiary care setting with a socially vulnerable patient population. Home-based head and neck lymphedema treatment showed improvements in patient diet over time.

Cutaneous Adverse Drug Reactions Associated with SGLT2 Inhibitors

Diabetes is a complex global healthcare burden involving multiple organ systems with its prevalence on the rise. SGLT2 inhibitors enhance glucose excretion. The objective of our literature review was to determine the association between cutaneous adverse drug reactions (CADRs) and the use of SGLT2 inhibitors. We collected data on CADRs related to the use of SGLT2 inhibitors from all available published articles and studied their details to understand the patterns of their association. PubMed, Cochrane, Google, and Embase were searched for relevant articles. A total of 37 papers were included and studied. Most articles were case reports followed by pharmacovigilance studies, case series, and reviews. The cutaneous findings ranged from benign eruptions to severe reactions. The available literature suggests a strong link between the use of SGLT2 inhibitors and Fournier’s gangrene/necrotizing fasciitis. T2DM patients using SGLT2 inhibitors have also developed fixed drug eruptions, drug-induced pruritus, and Sweet syndrome/acute febrile neutrophilic dermatosis, among other skin lesions. We found that SGLT2 inhibitors present a risk of developing CADRs. Raising awareness among healthcare providers regarding CADRs to SGLT2 inhibitors can reduce complications, minimize hospitalizations, and improve patient care in the vulnerable population of diabetes patients.

Distinct Neutralising and Complement-Fixing Antibody Responses Can Be Induced to the Same Antigen in Haemodialysis Patients After Immunisation with Different Vaccine Platforms

Background/Objectives: Generalised immune dysfunction in chronic kidney disease, especially in patients requiring haemodialysis (HD), significantly enhances the risk of severe infections. Vaccine-induced immunity is typically reduced in HD populations. The SARS-CoV-2 pandemic provided an opportunity to examine the magnitude and functionality of antibody responses in HD patients to a previously unencountered antigen—Spike (S)-glycoprotein—after vaccination with different vaccine platforms (viral vector (VV); mRNA (mRV)). Methods: We compared the total and functional anti-S antibody responses (cross-variant neutralisation and complement binding) in 187 HD patients and 43 healthy controls 21–28 days after serial immunisation. Results: After 2 doses of the same vaccine, HD patients had anti-S antibody levels and a complement binding capacity comparable to controls. However, 2 doses of mRV induced greater polyfunctional antibody responses than VV (defined by the presence of both complement binding and cross-variant neutralisation activity). Interestingly, an mRV boost after 2 doses of VV significantly enhanced antibody functionality in HD patients without a prior history of SARS-CoV-2 infection. Conclusions: HD patients can generate near-normal, functional antigen-specific antibody responses following serial vaccination to a novel antigen. Encouragingly, exploiting immunological memory by using mRNA vaccines and boosting may improve the success of vaccination strategies in this vulnerable patient population.

Assessing the prognostic impact of body composition phenotypes on surgical outcomes and survival in patients with spinal metastasis: a deep learning approach to preoperative CT analysis.

The prognostic significance of body composition phenotypes for survival in patients undergoing surgical intervention for spinal metastases has not yet been elucidated. This study aimed to elucidate the impact of body composition phenotypes on surgical outcomes and 5-year survival. The records of patients treated surgically for spinal metastases between 2010 and 2020 were retrospectively evaluated. A deep learning pipeline assessed preoperative CT scans obtained within 3 months of surgery and identified muscle and fat content and composition. These data were used to categorize patients into 4 body composition phenotypic groups: 1) not sarcopenic, not obese; 2) sarcopenia alone; 3) obesity alone; and 4) sarcopenic obesity (SO). The groups were matched using a comprehensive propensity-matching procedure. Rates of postoperative outcomes and survival were evaluated. Cox proportional hazard models were used to evaluate the influence of body composition phenotypes on 5-year survival. Kaplan-Meier plots were used to evaluate survival probability further. Following a propensity-matching procedure, 102 matched patient records were identified (not sarcopenic, not obese, n = 24; sarcopenia alone, n = 27; obesity alone, n = 37; and SO, n = 14). SO was found to be associated with a significantly increased mortality risk within 60 months (HR 3.27, 95% CI 1.43-7.48). Kaplan-Meier plots demonstrate evident divergence in survival probability within 5 years among patients in the SO group compared to the others (log-rank test, p = 0.022). Additionally, time to death was also lower in patients with SO (p = 0.018). Significant differences in postoperative ambulation rates were noted among patients with SO (p = 0.048), whereas no preoperative difference existed (p = 0.12). No significant differences in postoperative disposition, length of hospital stay, wound-related complications, or inpatient medical complications were otherwise noted (p > 0.05). This study identifies SO as a distinct prognostic factor for increased mortality risk in patients undergoing surgery for spinal metastases, highlighting the complex interplay between body composition and patient outcomes. These findings advocate for integrating body composition analysis into preoperative assessment and tailored postoperative care strategies, promoting personalized treatment plans to improve survival and quality of life for this vulnerable patient population.

Preparing for stormy weather: building VA health system resilience for dialysis emergency preparedness in the era of climate change.

Climate change has been implicated as the driver for the increasing number, intensity, duration, and consequences of catastrophic weather events. As a result of extreme weather events, climate change has also been implicated as an important mediator of adverse kidney health outcomes, not only increasing the risk for the development of acute and chronic kidney diseases, but also disrupting the delivery of critical kidney health services. In particular, the delivery of dialysis services during major emergencies remains an ongoing and increasing problem, with a recognized need for improved emergency preparedness and disaster management (EP-DM) strategies to mitigate the increased risk of morbidity and mortality associated with missed dialysis treatment. There are increasing reports detailing the challenges of kidney dialysis care in times of crisis, to include those resulting from both man-made and natural disasters. Optimized management of the high-risk vulnerable dialysis patient population must include both facility-facing comprehensive continuity of operations and emergency response plans, and ongoing patient-facing emergency preparedness education. This review discusses the adverse impact of climate change-related natural disasters on the delivery of dialysis services, and the evolving EP-DM strategies developed and implemented by the Veterans Health Administration (VA) to optimize the care and well being of the vulnerable end stage kidney disease (ESKD) patient population.

Assessing the acceptability to general practitioners of the French College of General Medicine’s recommendations on considering patients’ social situations: a Delphi study

BackgroundSocial determinants of health (SDH) impact the health status of individuals around the world. General practitioners (GPs) can take into account the social situation of patients in their care practice....

Ensuring equity in psychosocial risk assessment for solid organ transplantation: a review.

This review summarizes the different instruments for evaluating the psychosocial health of transplant candidates, the evidence demonstrating how these instruments relate to probability of transplant waitlisting and transplant outcomes, and the critical knowledge gaps that exist in the causal pathway between psychosocial health and clinical transplant trajectory. The current literature reveals that psychosocial assessments are a common reason for racial and ethnic minorities to be denied access to the transplant list. Given evidence that a lack of clinician consensus exists regarding the definition of, importance of, and reproducibility of psychosocial support evaluations, this facet of the holistic evaluation process may create a unique challenge for already vulnerable patient populations. Though recent evidence shows that psychosocial evaluation scores predict select transplant outcomes, these findings remain inconsistent. Multiple instruments for psychosocial transplant evaluation exist, though the utility of these instruments remains uncertain. As equity becomes an increasingly urgent priority for the transplant system, rigorous interrogation of the causal pathway between psychosocial health and transplant longevity is still needed.

Which Chemotherapy-Related Terms were Difficult for Cancer Patients, and Who Would Have the Most Difficulties?

This cross-sectional study aimed to examine which chemotherapy (CTx) terms were most difficult to understand for cancer patients and identify vulnerable patient populations who might need extra support to understand the terms. We listed 56 CTx-related terms based on the experts' review, then 300 cancer patients and their caregivers completed a questionnaire that assessed literacy in CTx terms (LCT), functional health literacy, and empowerment. Descriptive analysis was performed to examine which CTx-related terms were most difficult for them. Logistic regression analyses were performed to identify factors associated with LCT level. Of the total 300 people, 162 (54.0%) were in the low-scoring (LS) group in LCT. LS group had a higher proportion of males, lower monthly income, and lived at the province, compared to the high scoring (HS) group. The participants tended to have difficulties in understanding terms related to blood count, risk of infection, and symptoms written in Sino-Korean. In the multivariable logistic regression, male participants (Adjusted Odds Ratio [aOR] = 2.59, 95% confidence interval [CI]: 1.48-4.62), those with no cancer-related information-seeking (aOR = 4.32, 95% CI: 1.75-12.33), and those with low empowerment (aOR = 3.07, 95% CI: 1.83-5.23) were more likely to have a low level of LCT. There were still linguistic health literacy challenges faced by cancer patients and their caregivers, specifically in understanding chemotherapy-related terms. Minimizing medical jargon and Sino-Korean terms and empowering patients to be ready for treatment are necessary.

Think With Your Gut: A Retrospective Analysis on the Effects of Chronic Gastrointestinal Illness and Psychiatric Comorbidities.

As mental health awareness increases, healthcare professionals must understand the interplay between chronic gastrointestinal (GI) conditions and psychological well-being, particularly regarding healthcare utilization. This study uniquely aggregates various chronic GI disorders, such as inflammatory bowel disease, celiac disease, and eosinophilic esophagitis, to examine their impact on depression and anxiety. Utilizing a retrospective observational design, we analyzed data from 34,876 patients admitted to HCA national hospitals from January 2016 to December 2022. We found that patients with GI conditions and comorbid psychiatric disorders had significantly higher readmission rates and longer hospital stays compared to those without mental health diagnoses. Results indicated that patients with GI disorders and depression or anxiety were 1.29 times more likely to be readmitted within 90 days and had 1.50 times longer hospital stay. These findings underscore the importance of integrated care approaches addressing physical and mental health in managing chronic GI conditions. Future research should focus on targeted interventions to enhance mental health management and improve outcomes in this vulnerable patient population.

The Recovery of Consciousness via Evidence-Based Medicine and Research (RECOVER) Program: A Paradigm for Advancing Neuroprognostication.

Neuroprognostication for disorders of consciousness (DoC) after severe acute brain injury is a major challenge, and the conventional clinical approach struggles to keep pace with a rapidly evolving literature. Lacking specialization, and fragmented between providers, conventional neuroprognostication is variable, frequently incongruent with guidelines, and prone to error, contributing to avoidable mortality and morbidity. We review the limitations of the conventional approach to neuroprognostication and DoC care, and propose a paradigm entitled the Recovery of Consciousness Via Evidence-Based Medicine and Research (RECOVER) program to address them. The aim of the RECOVER program is to provide specialized, comprehensive, and longitudinal care that synthesizes interdisciplinary perspectives, provides continuity to patients and families, and improves the future of DoC care through research and education. This model, if broadly adopted, may help establish neuroprognostication as a new subspecialty that improves the care of this vulnerable patient population.

Dissemination and Implementation - A Primer for Accelerating "Time to Translation" in Radiation Oncology.

The field of radiation oncology has achieved significant technological and scientific advancements in the 21st century. Yet uptake of new evidence-based practices has been heterogeneous, even in the presence of national and international guidelines. Addressing barriers to practice change requires a deliberate focus on developing and testing strategies tailored to improving care delivery and quality, especially for vulnerable patient populations. Implementation science provides a systematic approach to developing and testing strategies, though applications in radiation oncology remain limited. In this critical review, we aim to 1) assess the time from first evidence to widespread adoption, or "time to translation," across multiple evidence-based practices involving radiation therapy, and 2) provide a primer on the application of implementation science to radiation oncology. Specifically, we discuss potential targets for implementation research in radiation oncology, including both evidence-based practices and quality metrics, and highlight examples of studies evaluating implementation strategies. We also define key concepts and frameworks in the field of implementation science, review common study designs including hybrid trials and cluster randomization, and discuss the interaction with related disciplines such as quality improvement and behavioral economics. Ultimately, this review aims to illustrate how a comprehensive understanding of implementation science could be used to promote equity and quality in cancer care through the development of effective, scalable, and sustainable care delivery solutions.

Congenital and Infantile Masses of the Head and Neck.

The spectrum of congenital and infantile masses of the head and neck is broad, including developmental and neoplastic entities. The diseases encountered in this vulnerable patient population differ substantially from those in older children and adults. Familiarity with the types of encountered masses, typical imaging characteristics, and expected clinical course is critical for radiologists who care for pregnant women (fetuses) and infants. This knowledge allows radiologists to provide a timely diagnosis and appropriate follow-up imaging recommendations and, in some fetal imaging cases, inform delivery planning. This article uses a location-based approach to highlight imaging features of numerous common and rare congenital and infantile masses of the head and neck. ©RSNA, 2024 Supplemental material is available for this article.

HEV Infection in Beta-Thalassemia Patients.

Thalassemia is an inherited hematological disorder characterized by a decrease in the synthesis of or absence of one or more globin chains. Hepatitis E virus (HEV) is a major cause of acute viral hepatitis, constituting a major global health burden and emerging as a critical public health concern. HEV infection is mainly transmitted via the fecal-oral route; however, parenteral transmission through blood components has been reported in both developing and developed countries. Although HEV infection is typically self-limiting, immunocompromised individuals, patients with chronic liver disease, and thalassemic patients are at a heightened risk of contracting the infection and may develop chronic hepatitis and life-threatening complications that require treatment. The reported prevalence rates of HEV in thalassemia patients vary significantly by country. Age, gender, residential area, and the cumulative amount of blood transfusions received have been identified as associated risk factors for HEV infection. In order to enhance blood safety and ensure the protection of vulnerable patient populations, such as thalassemia patients, several countries have introduced universal or targeted HEV screening policies in blood donations. Other preventive measures include vigilant monitoring of thalassemic patients and screening for anti-HEV antibodies. The aim of this review is to explore the prevalence, risk factors, clinical impact and management of HEV infection in patients with thalassemia.

Can Underlying Co-Morbidities Affect Cerebral Oximetry in Cardiac Surgery Patients?

Today, there is a growing number of monitoring Equipment accessible. These equipments ranging invasive to non-invasive. Choosing suitable monitoring methods depends on their benefits, drawbacks, and expenses. Overall, non-invasive brain monitoring is growing in importance because of its precision in performance and increased stability in output. Like the assessment of regional brain oxygen levels and the assessment of anesthesia depth using the BIS device, whose specific role in guidelines remains undefined. Many patients who undergo heart surgeries including valvular, dissection and CABG have various comorbidities. To add details, according to literatures about CVA 28% of patients had (Cerebrovascular Accident), 74% IHD (Ischemic Heart Disease), 82% HTN (Hypertension), 52% DM (Diabetes Mellitus), 61% Smoking History, 36% CKD (Chronic Kidney Disease) and 42% CHF (Congestive Heart Failure). Current study delves into the correlation of short-term complications after cardiac operations with cerebral oximetry alterations and the space under the curve (duration of rSo2 drop) to take the best advantages of cerebral oximetry for heart surgery in the future. This prospective observational study was conducted among 101 patients undergoing cardiac surgery at Imam Khomeini Hospital in Tehran between 2019 and 2020. Following admission to the operating room, standard monitoring of vital signs, including non-invasive blood pressure (NIBP), electrocardiogram (ECG), central venous pressure (CVP), oxygen saturation (SpO2), and end-tidal carbon dioxide (ETCO2), was established. Prior to anesthesia induction, cerebral oxygen saturation (rSO2) was continuously monitored using the INVOS 5100c cerebral oximeter. Patients were followed for 7 days postoperatively, with documentation of intubation duration, intensive care unit (ICU) stay, and complications such as renal failure, cerebrovascular accident (CVA), and mortality. Data analysis was performed using SPSS 25.0 statistical software, with a P of less than 0.05 considered statistically significant. This study investigated rSO2 levels, as measured by a cerebral oximeter, in patients aged 19 to 79 undergoing cardiac surgery. Data were collected from both the right and left sides of the forehead during the operative period. Overall, these findings highlight the importance of rSO2 monitoring during cardiac surgery, particularly in patients with underlying cardiovascular conditions. Further research is needed to elucidate the specific mechanisms underlying these observations and to explore potential strategies for optimizing cerebral oxygenation in this vulnerable patient population.

Danaparoid-Consensus Recommendations on Its Clinical Use.

(1) Background: Danaparoid sodium is a heparinoid antithrombotic that has been used for over 40 years for prophylaxis of DVT in non-HIT patients and for the treatment of heparin-induced thrombocytopenia (HIT) with and without thrombosis. This update summarises current information on its pharmacology and reviews danaparoid dose management in a broad spectrum of clinical situations, including off-label indications. (2) Methods: Evidence from published clinical studies, case reports, compassionate use of danaparoid, and spontaneously reported serious adverse events is summarised and analysed by an interdisciplinary expert group to develop a consensus on dosing regimens of danaparoid for complex clinical situations, including vulnerable patient populations. (3) Results: Dosing regimens are proposed, together with monitoring recommendations and target anti-factor Xa ranges. (4) Conclusion: In a comprehensive summary detailed interdisciplinary dosing recommendations are described to provide a basis for safe and effective use of danaparoid.

Racial disparities in the frequency and timing of code status orders among women with breast cancer

BackgroundBlack/African American women with breast cancer have a disproportionately higher risk of mortality compared to other race groups, although their overall incidence of disease is lower. Despite this, advance care planning (ACP) and consequent code status documentation remain low in this vulnerable patient population. Code status orders (i.e., Full code, Do Not Attempt Resuscitation [DNAR], Do Not Intubate [DNI]) allow consideration of patient preferences regarding the use of aggressive treatments, such as cardiopulmonary resuscitation and intubation. The aim of this study is to characterize presence of code status orders and determine whether race affects code status documentation after the first encounter for breast cancer.MethodsData were derived from 7524 women with breast cancer from the University of Chicago Medical Center (UCMC) between 2016 and 2021. Cox regression was used to estimate the effects of race and adjusted for age, ethnicity, inpatient stays, metastatic breast cancer, marital status, and body mass index.ResultsThe sample included 60.5% White, 3.6% Asian/Mideast Indian, 28.9% Black/African American, and 7.0% other or unknown race. Results indicate that code status orders after the first breast cancer encounter were uncommon (7.2%). Black/African American race (HR = 2.74; 95% CI: 1.75, 4.28) emerged as a significant factor associated with any code status orders compared to other race groups even when adjusting for covariates.ConclusionsCode status documentation in this sample of women with breast cancer was low overall, yet rates were higher among Black/African American patients compared to other race groups. In fact, race remains a significant predictor of code status documentation even when accounting for indirect measures of cancer severity. This could be denoting the racial disparities (e.g., higher cancer malignancy such as triple negative breast cancer) in breast cancer mortality risk. Future research is needed to identify factors unique to Black/African American women that would increase code status documentation so that goal concordant care can be prioritized among patients with breast cancer.

Outcomes of Urgent Coronary Artery Bypass Graft Surgery Following Non-ST Elevation Myocardial Infarction

Background: Non-ST elevation myocardial infarction (NSTEMI) significantly reduces patient survival, a condition that is essential for the optimization of results and the restoration of effective vascular flow multivessel coronary artery disease, Emergency coronary artery bypass grafting (CABG) is frequently contemplated. In the aftermath of NSTEMI, the objective of this investigation is to assess the results of urgent CABG, to prioritize risk stratification through the use of the Global Registry of Acute Coronary Events (GRACE) score Methods: An analysis of 60 consecutive patients who underwent emergent CABG following NSTEMI was conducted retrospectively. Data on patients were obtained from a prospectively compiled database, and the GRACE score was implemented to evaluate the probability of mortality. Patients were divided into three risk categories: low (<10%), intermediate (10-19%), and high (≥20%), based on their predicted mortality percentages. Results: Patients in the high-risk group (Group 3) exhibited significantly lower Euro Scores and ejection fractions (EF) than those in the low and intermediate groups, as demonstrated by the study. Additionally, the cross-clamp time was notably longer in Group 3, highlighting the urgency of intervention in this population The postoperative complications' overall incidence did not differ significantly between the groups. Even though Group 3 exhibited an increased in-hospital mortality rate. Conclusions: The findings underscore the importance of timely intervention and tailored management strategies for NSTEMI patients, more specifically, the individuals who have been classified as high-risk by the GRACE score. This study contributes to the growing body of literature supporting urgent CABG as a lifesaving procedure and emphasizes the need for further research to optimize outcomes in this vulnerable patient population. The results advocate for a multidisciplinary approach to enhance perioperative care and improve survival rates among NSTEMI patients undergoing CABG.

Long-Acting Cabotegravir Plus Rilpivirine in People with HIV with Adherence Challenges and Viremia: Current Data and Future Directions.

Long-acting injectable cabotegravir plus rilpivirine (LA CAB/RPV) is currently US Food and Drug Administration (FDA)-approved and HIV treatment guideline-endorsed as a switch strategy for patients with HIV (PWH) who are virologically suppressed on oral ART without a history of treatment failure. Recent changes to the International Antiviral Society-USA (IAS-USA) and U.S. Department of Health and Human Services' (DHHS) Panel on Antiretroviral Guidelines recommend the consideration of LA CAB/RPV in select PWH with viremia who are unable to achieve suppression with oral ART due to suboptimal medication adherence. In this article, we review the existing data on this off-label use of LA CAB/RPV, discuss the motivations and specific caveats implicit in the guidelines change, and propose next steps in exploring this novel treatment in this vulnerable patient population.