Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

Tracing clinically-relevant antimicrobial resistances in Acinetobacter baumannii-calcoaceticus complex across diverse environments: A study spanning clinical, livestock, and wastewater treatment settings

Acinetobacter baumannii has become a prominent nosocomial pathogen, primarily owing to its remarkable ability to rapidly acquire resistance to a wide range of antimicrobial agents and its ability to persist in diverse environments. However, there is a lack of data on the molecular epidemiology and its potential implications for public health of A. baumannii strains exhibiting clinically significant resistances that originate from non-clinical environments. Therefore, the genetic characteristics and resistance mechanisms of 80 A. baumannii-calcoaceticus (ABC) complex isolates, sourced from environments associated with poultry and pig production, municipal wastewater treatment plants (WWTPs), and clinical settings, were investigated. In total, our study classified 54 isolates into 29 previously described sequence types (STs), while 26 isolates exhibited as-yet-unassigned STs. We identified a broad range of A. baumannii STs originating from poultry and pig production environments (e.g., ST10, ST238, ST240, ST267, ST345, ST370, ST372, ST1112 according to Pasteur scheme). These STs have also been documented in clinical settings worldwide, highlighting their clinical significance. These findings also raise concerns about the potential zoonotic transmission of certain STs associated with livestock environments. Furthermore, we observed that clinical isolates exhibited the highest diversity of antimicrobial resistance genes (ARGs). In contrast to non-clinical isolates, clinical isolates typically carried a significantly higher number of ARGs, ranging from 10 to 15. They were also the exclusive carriers of biocide resistance genes and acquired carbapenemases (blaOXA-23, blaOXA-58, blaOXA-72, blaGIM-1, blaNDM-1). Additionally, we observed that clinical strains displayed an increased capacity for carrying plasmids and undergoing genetic transformation. This heightened capability could be linked to the intense selective pressures commonly found within clinical settings. Our study provides comprehensive insights into essential aspects of ABC isolates originating from livestock-associated environments and clinical settings. We explored their resistance mechanisms and potential implications for public health, providing valuable knowledge for addressing these critical issues.

Hidradenitis Suppurativa-Related Autoinflammatory Syndromes: An Updated Review on the Clinics, Genetics, and Treatment of Pyoderma gangrenosum, Acne and Suppurative Hidradenitis (PASH), Pyogenic Arthritis, Pyoderma gangrenosum, Acne and Suppurative Hidradenitis (PAPASH), Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis (SAPHO), and Rarer Forms

Hidradenitis suppurativa (HS) is an autoinflammatory skin disorder of the terminal hair follicle, which can present in sporadic, familial, or syndromic form. A classification has been proposed for the latter, distinguishing cases associated with a known genetic condition, with follicular keratinization disorders or with autoinflammatory diseases. This review focuses on the clinical and genetic features of those entities (ie, pyoderma gangrenosum [PG], acne and HS; PG, acne, pyogenic arthritis and HS; psoriatic arthritis, PG, acne and HS; synovitis, acne, pustulosis, hyperostosis, osteitis; and so forth) for which the collective term HS-related autoinflammatory syndromes is proposed.

Be aware of childhood stroke: Proceedings from EPNS Webinar

Childhood arterial ischaemic stroke (AIS) is a significant health concern with increasing incidence. This review aims to provide an overview of the current understanding of childhood AIS. The incidence of childhood AIS is on the rise especially in developing countries, likely due to improved awareness and diagnostic capabilities. Aetiology of childhood AIS is multifactorial, with both modifiable risk factors and genetic predisposition playing important roles. Identifying and addressing these risk factors, such as infection, sickle cell disease, and congenital heart defects, is essential in prevention and management. Identifying underlying conditions through genetic testing is important for appropriate management and long-term prognosis. Clinically, distinguishing stroke from stroke mimics can be challenging. Awareness of important stroke mimics, including migraines, seizures, and metabolic disorders, is crucial to avoid misdiagnosis and ensure appropriate treatment. The diagnostic approach to childhood AIS involves a comprehensive "chain of care," including initial assessment, neuroimaging, and laboratory investigations. National guidelines play a pivotal role in standardizing and streamlining the diagnostic process, ensuring prompt and accurate management. Early intervention is critical in the management of childhood AIS. Due to the critical time window, the question if mechanical thrombectomy is feasible and beneficial should be addressed as fast as possible. Early initiation of antiplatelet or anticoagulation therapy and, in select cases, thrombolysis can help restore blood flow and minimize long-term neurological damage. Additionally, rehabilitation should start as soon as possible to optimize recovery and improve functional outcomes. In conclusion, childhood AIS is a growing concern. Understanding the increasing incidence, age distribution, risk factors, clinical presentation, diagnostic approach, and management strategies is crucial for optimized management of these patients.

Experiences of rural nurses with emergency patient transport in a resource limited setting

BACKGROUND

Registered nurses are primary care providers during most patient transfers from rural areas. Various local conditions and circumstances impact the provision of nursing care prior to and during transportation. These include clinic staffing, uneven access to functioning equipment and other necessary infrastructure across settings, the wide-ranging clinical need for specialty care, and complex social and interpersonal circumstances that play a role in care-seeking and transport decision-making. This study explored the experiences of nurses with emergency patient transport in rural health facilities in Botswana.

METHOD

A qualitative descriptive approach was used using a semi structured interview. Twenty-six registered nurses from four remote, isolated rural health districts in Botswana participated in this study. Purposive convenience sampling technique was employed.

RESULTS

The ten main themes under transporter were infringement of scope of practice, inadequate knowledge and skills, distressful practice, restriction from making decisions, challenges with staffing, Ineffective facilities clustering, lack of support from the managers, shortage of technology and tools, non-enabling infrastructure, and transport related tasks.

DISCUSSION AND CONCLUSION

The perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport.

REI clinics and fellowship training-a national snapshot to improve access to reproductive care

PURPOSE

To analyze the geographic distribution of REI fellowships and clinics across the USA and to strategize ways to improve patient access to care.

METHODS

Cross-sectional study using population data obtained from publicly available United States Census Bureau, Society for Assisted Reproductive Technology (SART), and National Resident Matching Program websites. Outcomes include the number of REI clinics, REI fellowship-trained physicians, and REI fellowship programs.

RESULTS

In 2020, there were 643 assisted reproductive technology (ART) clinics reporting to SART and 1351 fellowship-trained REI physicians. Most clinics are located in the south (n = 209); however, the northeast has the highest density of REI clinics. Out of 301,316 in vitro fertilization (IVF) cycles in the USA in 2020, northeastern states initiated the most cycles (n = 93,565), and Midwestern states initiated the fewest cycles (n = 50,000). The northeast has the most REI physicians per million women aged 20-44 years (42.4) while the Midwest has the lowest ratio (19.5). There are fewer REI physicians per million women aged 20-44 years in states with a lower proportion of patients with health insurance (r = 0.56, 95% confidence interval ([CI] 0.34-0.73) and in states with a lower average income per resident (r = 0.65, 95% CI 0.46-0.79). Most of the 49 accredited REI fellowship programs in the USA are in the northeast (n = 18), and there are fewest in the south (n = 10) and west (n = 10).

CONCLUSION

Access to REI care has large geographic disparities from a clinic, physician, and training program perspective. Creative solutions are needed to remedy this problem.

Muscle synergies for evaluating upper limb in clinical applications: A systematic review

INTRODUCTION

Muscle synergies have been proposed as a strategy employed by the central nervous system to control movements. Muscle synergy analysis is a well-established framework to examine the pathophysiological basis of neurological diseases and has been applied for analysis and assessment in clinical applications in the last decades, even if it has not yet been widely used in clinical diagnosis, rehabilitative treatment and interventions. Even if inconsistencies in the outputs among studies and lack of a normative pipeline including signal processing and synergy analysis limit the progress, common findings and results are identifiable as a basis for future research. Therefore, a literature review that summarizes methods and main findings of previous works on upper limb muscle synergies in clinical environment is needed to i) summarize the main findings so far, ii) highlight the barriers limiting their use in clinical applications, and iii) suggest future research directions needed for facilitating translation of experimental research to clinical scenarios.

METHODS

Articles in which muscle synergies were used to analyze and assess upper limb function in neurological impairments were reviewed. The literature research was conducted in Scopus, PubMed, and Web of Science. Experimental protocols (e.g., the aim of the study, number and type of participants, number and type of muscles, and tasks), methods (e.g., muscle synergy models and synergy extraction methods, signal processing methods), and the main findings of eligible studies were reported and discussed.

RESULTS

383 articles were screened and 51 were selected, which involved a total of 13 diseases and 748 patients and 1155 participants. Each study investigated on average 15 ± 10 patients. Four to forty-one muscles were included in the muscle synergy analysis. Point-to-point reaching was the most used task. The preprocessing of EMG signals and algorithms for synergy extraction varied among studies, and non-negative matrix factorization was the most used method. Five EMG normalization methods and five methods for identifying the optimal number of synergies were used in the selected papers. Most of the studies report that analyses on synergy number, structure, and activations provide novel insights on the physiopathology of motor control that cannot be gained with standard clinical assessments, and suggest that muscle synergies may be useful to personalize therapies and to develop new therapeutic strategies. However, in the selected studies synergies were used only for assessment; different testing procedures were used and, in general, study-specific modifications of muscle synergies were observed; single session or longitudinal studies mainly aimed at assessing stroke (71% of the studies), even though other pathologies were also investigated. Synergy modifications were either study-specific or were not observed, with few analyses available for temporal coefficients. Thus, several barriers prevent wider adoption of muscle synergy analysis including a lack of standardized experimental protocols, signal processing procedures, and synergy extraction methods. A compromise in the design of the studies must be found to combine the systematicity of motor control studies and the feasibility of clinical studies. There are however several potential developments that might promote the use of muscle synergy analysis in clinical practice, including refined assessments based on synergistic approaches not allowed by other methods and the availability of novel models. Finally, neural substrates of muscle synergies are discussed, and possible future research directions are proposed.

CONCLUSIONS

This review provides new perspectives about the challenges and open issues that need to be addressed in future work to achieve a better understanding of motor impairments and rehabilitative therapy using muscle synergies. These include the application of the methods on wider scales, standardization of procedures, inclusion of synergies in the clinical decisional process, assessment of temporal coefficients and temporal-based models, extensive work on the algorithms and understanding of the physio-pathological mechanisms of pathology, as well as the application and adaptation of synergy-based approaches to various rehabilitative scenarios for increasing the available evidence.

Analysis of the annual changes in dental institutions that claimed dental sedatives in Korea and the types of sedatives using health care big data

Background

Dentists make various efforts to reduce patients' anxiety and fear associated with dental treatment. Dental sedation is an advanced method that dentists can perform to reduce patients' anxiety and fear and provide effective dental treatment. However, dental sedation is different from general dental treatment and requires separate learning, and if done incorrectly, can lead to serious complications. Therefore, sedation is performed by a limited number of dentists who have received specific training. This study aimed to investigate the proportion of dentists who practice sedation and the main sedatives they use in the context of the Republic of Korea.

Methods

We used the customized health information data provided by the Korean National Health Insurance. We investigated the number of dental hospitals or clinics that claimed insurance for eight main sedatives commonly used in dental sedation from January, 2007 to September, 2019 at the Health Insurance Review and Assessment Service. We also identified the changes in the number of dental medical institutions by region and year and analyzed the number and proportion of dental medical institutions prescribing each sedative.

Results

In 2007, 302 dental hospitals prescribed sedatives, and the number increased to 613 in 2019. In 2007, approximately 2.18% of the total 13,796 dental institutions prescribed sedatives, increasing to 3.31% in 2019. In 2007, 168 institutions (55.6%) prescribed N₂O alone, and in 2019, 510 institutions (83.1%) made claims for it. In 2007, 76 (25.1%) hospitals made claims for chloral hydrate, but the number gradually decreased, with only 29 hospitals (4.7%) prescribing it in 2019. Hospitals that prescribed a combination of N₂O, chloral hydrate, and hydroxyzine increased from 27 (8.9%) in 2007 to 51 (9%) in 2017 but decreased to 38 (6.1%) in 2019. The use of a combination of N₂O and midazolam increased from 20 hospitals (6.6%) in 2007 to 51 hospitals (8.3%) in 2019.

Conclusion

While there is a critical limitation to the investigation of dental hospitals performing sedation using insurance claims data, namely exclusion of dental clinics providing non-insured treatments, we found that in 2019, approximately 3.31% of the dental clinics were practicing sedation and that N₂O was the most commonly prescribed sedative.

European survey on valvular heart disease clinical experience from the European Society of Cardiology council on valvular heart disease

Aims

The aim of this survey is to analyze how current recommendations on valvular heart disease (VHD) management have been adopted. Identifying potential discrepancies between recommendations and everyday clinical practice would enable us to better understand and address the remaining challenges in this controversial and complex field.

Methods and results

A total of 33 questions, distributed via email to all European Society of Cardiology (ESC) affiliated countries through the newsletter of the ESC council on VHD, were answered by 689 respondents, mainly from tertiary care settings. The results of this survey showed that VHD patients are mostly managed by tertiary care centres, where multi-disciplinary heart teams are frequently a reality. Cardiac computed tomography (CT) is often used in the preprocedural planning of transcatheter interventions, particularly for sizing and deliverability assessment. Echocardiography represents the most widely used imaging modality in the diagnostic, intra-operative and follow-up phase of VHD patients. Cardiac magnetic resonance (CMR) is still largely underused, also for conditions such as mitral annular disjunction, or for the assessment of left ventricle volumes where it is considered as the gold standard, despite 3D volumes by echocardiography having proved good comparability with CMR. As for endocarditis, despite still underused, transesophageal echocardiography (TEE) represents the approach of choice for the diagnosis of native and prosthesis valve endocarditis (up to 46% of the respondents use it). In this context, positron emission tomography-CT is largely underused.

Conclusion

There is widespread adoption of current recommendation on the evaluation of VHD and these are frequently used to guide patient management. Nonetheless, there are still many discrepancies across centres and countries which need to be addressed with the aim of improving patients' management and outcomes and ultimately positively impacting on healthcare resources.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is included within the spondyloarthritis, a group of rheumatological diseases characterized by different clinical manifestations and associated comorbidities, that can compromise the quality of life of patients. The diagnosis of PsA is sometimes difficult due to an enormous clinical and radiological variability, including six different domains of involvement: peripheral joint, axial skeleton, skin psoriasis, nail psoriasis, enthesitis and dactylitis. Currently, there are no biomarkers that allow the detection of PsA in patients with psoriasis, so a high level of suspicion is important, mainly by dermatologists, but also by other specialists, such as family doctors. Advances in the knowledge of new immunological mechanisms and joint management by rheumatologists and dermatologists have made it possible to improve the therapeutic approach in patients with PsA.

Clinical effectiveness and cost-effectiveness of ambulatory heart failure nurse-led services: an integrated review

Background

Globally the burden of heart failure is rising. Hospitalisation is one of the main contributors to the burden of heart failure and unfortunately, the majority of heart failure patients will experience multiple hospitalisations over their lifetime. Considering the high health care cost associated with heart failure, a review of economic evaluations of post-discharge heart failure services is warranted.

Aim

An integrated review of the economic evaluations of post-discharge nurse-led heart failure services for patients hospitalised with acute heart failure.

Methods

Electronic databases were searched using EBSCOHost: CINAHL complete, Medline complete, Embase, Scopus, EconLit, Global Health, and Health source (Consumer and Nursing/Academic) for published articles until 22nd June 2021. The searches focussed on papers that examined the cost-effectiveness of nurse-led clinics or telemonitoring involving nurses to follow-up patients after hospitalisation for acute heart failure. GRADE criteria and CHEERS checklist were used to determine the quality of the evidence and the quality of reporting of the economic evaluation.

Results

Out of 453 studies identified, eight studies were included: four in heart failure clinics and four in telemonitoring programs. Five of the articles were cost-effectiveness analyses, one a cost comparison and two studies involved economic modelling The GRADE criteria were rated as high in five studies. In which, four studies examined the cost-effectiveness of telemonitoring programs. Based on the CHEERS checklist for reporting quality of economic evaluations, the majority of economic evaluations were rated between 86 and 96%. All the studies found the intervention to be cost-effective compared to usual care with Incremental Cost Effectiveness Ratios ranging from $18 259 (Canadian dollars)/life year gained to €40,321 per Quality Adjusted Life Years gained.

Conclusion

Nurse-led heart failure clinics and telemonitoring programs were found to be cost-effective. Certainly, this review has shown that heart failure clinics and telemonitoring programs do represent value for money with their greatest impact and cost savings through reducing rehospitalisations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02509-9.

[Cerebral-meningeal hemorrhage secondary to snakebite envenomation: about two cases at the Sourô Sanou Teaching Hospital in Bobo-Dioulasso, Burkina Faso]

Background

Envenomation by snakebite is a public health problem in developing countries. Neurovascular complications are uncommon. We report two cases of hemorrhagic stroke at the Sourô Sanou Teaching Hospital in Bobo-Dioulasso, which complicate an envenomation.

Clinical description

The first patient was a 60-year-old woman with no history, who had been admitted 2 hours after snakebite for gingivorrhagia and consciousness disorders. Clinical examination found coma (GCS 7/15) and tetraparesis. The second patient was a 50-year-old woman with no history, who had been admitted one week after snakebite with digestive bleeding. Clinical examination found right hemiplegia and meningeal syndrome. Both patients presented hemorrhagic stroke on brain CT-scan but hemostasis assessment was normal. They received polyvalent antivenom and symptomatic treatment. The outcome was favorable for survival but with sequelae like tetraparesis for first patient and hemiparesis for second patient.

Discussion - Conclusion

The hemorrhagic strokes are rare complications of snake envenomation. Venomous toxins can directly lead to the rupture of intracranial vessels apart of abnormalities of hemostasis. However, the morbidity and mortality related to envenomation by snake bite remains high in our environment.

Acute-on-chronic liver failure in children

Although various complex definitions of acute-on-chronic liver failure (ACLF) have been suggested in relation to adult patients, there is currently no universal definition of the syndrome in pediatric patients. In simplified terms, ACLF is characterized by the acute deterioration of the liver functions due to the effects of a precipitating factor on the basis of a chronic liver disease. Acute events and underlying liver diseases are very different in children from those seen in adults. Moreover, acute events and underlying chronic liver diseases vary among geographical regions, although it seems that the most common such diseases and acute events are autoimmune hepatitis, Wilson’s disease, and their flares. ACLF is associated with a poor prognosis. While no scoring systems have been developed to predict the prognosis for children with ACLF, modified versions of the Asian Pacific Association for the Study of the liver’s acute-on-chronic liver failure scoring system and the Chronic Liver Failure-Sequential Organ Failure Assessment criteria can be used in children until specific and validated scoring systems are available. Aside from liver transplantation, there is no proven treatment for ACLF. Thus, the early recognition of ACLF prior to the development of extrahepatic organ failure is important.

A cross sectional study to assess tobacco use and its correlates among patients attending non-communicable disease clinics of a Northern Jurisdiction in India

Background:

Non-Communicable Diseases (NCDs) continue to rise unabated globally and the existing evidence has unequivocally established the relationship between tobacco use and NCDs. In 2010 the Government of India (GOI) introduced NCD clinics under the National Program for Prevention and Control of Cancer, Diabetes, Cardio Vascular Diseases and Stroke (NPCDCS) with the purpose of preventing and combating the NCD epidemic. This study was undertaken with an objective to comprehensively determine tobacco use and its correlates among patients attending these NCD clinics.

Methods:

A descriptive cross-sectional study was carried out among 1172 patients attending NCD clinics at district level, in Punjab, India between May to October 2018. Using systematic sampling every fourth patient was interviewed and equal numbers of visits were made to both the clinics.

Results:

Overall, the current tobacco use in any form was reported to be 10.2% among the study respondents. Majority of the tobacco users were males (23.3%), in 40–49 year age group, (18.7%), residing in urban area (15%), educated up to secondary school (18%) and non-government occupation bracket (27.4%) and hypertension disease category (41.6%). More SLT users had thought of quitting in past in comparison to smokers (46.6% vs 40%) and had higher quit attempts in past (42.5% vs 38.3%). In the binary logistic regression analysis, odds of tobacco use increased with increasing age, three times higher among participants who were employed (OR 3.75; CI 1.41-10.02),6 times higher in COPD disease category (OR 6.88; CI 2.1-20.59).

Conclusion:

Higher tobacco use among the NCD clinic attendees with increasing age predisposes them to develop grave complications. This calls for the need to administer intensive behaviour change interventions for tobacco cessation at the existing NCD clinics. This could further strengthen existing health systems and thereby improving health outcomes followed by achieving Sustainable Development Goals.

Screening and Treatment of Tobacco Use Disorder in Mental Health Clinics in New York State: Current Status and Potential Next Steps

The prevalence of smoking is higher among individuals with serious mental illnesses than the general population. Evidence-based practices exist for tobacco cessation, but little is known about mental health clinics' tobacco cessation treatment practices/protocols. Mental health clinics in New York State were surveyed about their tobacco use treatment protocols and outdoor-smoking policies. One-third of clinics were not providing individual counseling for tobacco use disorder, 39% were not prescribing nicotine replacement therapy, and nearly half reported not prescribing bupropion or varenicline. Even smaller proportions reported implementing other clinical practice guidelines, with only 25.2% providing staff training and 20.3% having a dedicated staff member for coordinating tobacco use disorder treatment. Regarding outdoor smoke-free policies, 38% of clinics reported not allowing any tobacco use anywhere on grounds. Despite some successes, many clinics do not provide evidence-based tobacco use treatments, meaning important opportunities exist for mental health clinics and oversight agencies to standardize practices.

Rationale and protocol for a cluster randomized, cross-over trial of recruitment methods of rural children in primary care clinics: A feasibility study of a pediatric weight control trial in the IDeA States Pediatric Clinical Trials Network

A significant percentage of clinical trials fail due to poor recruitment. Despite this, few studies exist to evaluate clinical trial recruitment strategies using a randomized approach in any population, and none exist to test recruitment strategies for trials involving children or rural populations. For clinical trials focused on weight control, evaluating retention and dose are extremely important, as poor retention can lead to biased samples and existing research shows that dose (i.e. contact hours) is directly related to patient outcome. Finally, adequacy of blinding of assessment teams is rarely reported in pediatric trials, and unblinded staff may be more likely to inadvertently bias findings. Therefore, in this feasibility trial we aim to use rigorous clinical trial methodology to assess the effectiveness of two different recruitment strategies, as well as test retention, dose, and blinding. Specifically, we describe the rationale, design, and planned implementation of a feasibility study of a rural pediatric obesity treatment trial that will be implemented in four medical clinics in four states affiliated with the Environmental influences on Child Health Outcomes IDeA States Pediatric Clinical Trials Network (ECHO ISPCTN). The primary objective is to assess recruitment rate for consecutive recruitment (approaching recently seen eligible patients in consecutive order by date seen) compared to traditional recruitment (such as posters, flyers, tear-offs), as well as to assess retention, dose, and blinding. If successful, this trial will support the implementation of a large multi-state trial directed at addressing obesity in rural children and their families recruited from their primary care clinics. Registered with ClinicalTrials.gov NCT ID NCT04142034.

Medical abortion offered in pharmacy versus clinic-based settings: A systematic review

OBJECTIVE

Expanding access to medical abortion through pharmacies is a potential strategy to promote safe abortion care. To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion.

STUDY DESIGN

We searched multiple databases and the gray literature through November 2020. No language restrictions were applied. We included randomized and nonrandomized comparative studies. We applied standard risk of bias tools to each included study and used GRADE methodology to assess certainty of evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion.

RESULTS

Our search yielded 2030 studies. One prospective cohort study from Nepal met inclusion criteria. This study collected data on 605 women obtaining medical abortion rom either a clinic or pharmacy, and was judged to have low risk of bias for our primary outcome. For women who received medical abortion in a pharmacy compared to a clinic there was probably little or no difference in complete abortion rates (adjusted risk difference 1.5%; 95% confidence interval [CI] -0.8 to 3.8, 1 study, 600 participants; low certainty of evidence). No cases of blood transfusion were reported in the study and a composite outcome comprised mainly of infection complications showed little or no difference between settings (adjusted risk difference 0.8; 95% CI -1.0 to 2.8, 1 study, 600 participants; very low certainty of evidence).

CONCLUSION

Evidence from just one nonrandomized study provides low certainty evidence that the effectiveness of medical abortion is probably not different between the pharmacy or clinic setting.

IMPLICATIONS

Provision of medical abortions through pharmacy-based models of care may improve access to safe abortion. Comparative studies examining each model of care and outcomes on safety, effectiveness, and patient experience are needed.

Clinical Appearance of Medial Ankle Instability

Whereas tenderness, ecchymosis, and swelling over the deltoid ligament have relatively poor sensitivity, resulting valgus and pronation deformity that is seen to disappear when the patient is asked to activate the posterior tibial muscle or to go in tiptoe position is the hallmark for the presence of medial ankle instability. A pain on palpation at anteromedial edge of the ankle confirms the diagnosis. Various stress tests permit to confirm and specify the injury pattern. A pseudo hallux rigidus is the consequence of a hyperactivity of flexor hallucis longus muscle to protect the foot against the valgus and pronation deformity.

A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.

Digital Clinics and Mobile Technology Implementation for Mental Health Care

PURPOSE OF REVIEW

Interest in digital mental health, especially smartphone apps, has expanded in light of limited access to mental health services and the need for remote care during COVID-19. Digital clinics, in which apps are blended into routine care, offer a potential solution to common implementation challenges including low user engagement and lack of clinical integration of apps.

RECENT FINDINGS

While the number of mental health apps available in commercial marketplaces continues to rise, there are few examples of successful implementation of these apps into care settings. We review one example of a digital clinic created within an academic medical center and another within the Department of Veterans Affairs. We then discuss how implementation science can inform new efforts to effectively integrate mental health technologies across diverse use cases. Integrating mental health apps into care settings is feasible but requires careful attention to multiple domains that will influence implementation success, including characteristics of the innovation (e.g., utility and complexity of the app), the recipients of the technology (e.g., patients and clinicians), and context (e.g., healthcare system buy-in, reimbursement, and regulatory policies). Examples of effective facilitation strategies that can be utilized to improve implementation efforts include co-production of technology involving all end users, specialized trainings for staff and patients, creation of new team members to aid in app usage (e.g., digital navigators), and re-design of clinical workflows.

Virtual voice clinics in the COVID-19 era: have they been helpful?

Purpose

In response to the coronavirus pandemic, a tertiary combined Laryngology-Speech Therapy voice clinic was converted to a wholly virtual clinic, with consultations carried out via telephone or video. The aim of our mixed method study was to assess (a) how effective are virtual clinics vs face-to-face clinics in progressing patients’ care and (b) what is patient satisfaction with virtual consultation methods.

Methods

Analysis of clinic data from patient databases for both virtual and face-to-face clinics was carried out. A patient satisfaction survey was carried out by 75 of the patients who had attended virtual clinics.

Results

There was statistically a significant difference (p value < 0.01) in the proportion of patients prescribed medical therapy, referred for Speech and Language Therapy (SALT) or listed for surgery in the virtual clinic by comparison to the face-to-face clinic. 75 patients completed the questionnaire. 98% of patients were satisfied overall with the virtual method of consultation. 84% believed they would still benefit from face-to-face review. 83% would like the option of a virtual type of clinic in the future.

Conclusion

Our data clearly demonstrates that face-to-face clinics are superior to virtual clinics, with almost no patients progressed to surgery in virtual consultations. Despite this, virtual methods are still valuable, and many patients have meaningful progression of care. In current circumstances, patients have very high satisfaction with virtual consultations and certain groups have been identified as particularly benefiting. Going forward, an ideal clinic may be a hybrid of face-to-face and virtual appointments as clinically indicated.

Coping strategies among patients attending HIV clinics in a North-central State of Nigeria

Background

Nigeria ranks third among the countries with the highest HIV/AIDS burden in the world, next only to India and South Africa. The North-Central zone which Kwara State belongs to has the highest concentration of HIV prevalence rate of 7.5%, while the North-Western zone recorded the lowest prevalence of 2.1%; Kwara state has a prevalence rate of 2.2%.

Aims

The study assessed the coping strategies adopted by patients attending HIV clinics in a North-central city of Nigeria.

Methods

The study design was descriptive cross-sectional involving 384 HIV-positive patients who were systematically recruited at 5 public service delivery sites in Ilorin- a North-central city, Nigeria was used for the study. Coping strategies were measured using the Brief COPE scale. Data were analyzed using SPSS software version 20.0. Level of significance was pre-determined at P value <0.05 at a confidence level of 95%.

Results

Female respondents constituted 222 (58.0%) while males were 162 (42.0%). Respondents experienced varying proportion of coping strategies of which Self-distraction 288 (75.0%), active coping 249 (64.8%), emotional support 228 (59.4%), among others were the major strategies adopted by respondents.

Conclusion

HIV is a chronic disease with heavy burden on both patients and health facility rendering services for the care of these patients. A good proportion of respondents interviewed adopted varying coping strategies. Sustained social and psychological support will improve further the coping strategies of living with HIV.

[The Ultrasonographic Features of Female Reproductive System Extraosseous Ewing's Sarcoma]

OBJECTIVE

This study investigated the clinicopathological traits and ultrasound features of female reproductive system extraosseous Ewing's sarcoma (EES) and explored the diagnostic value of ultrasonography for this condition.

METHODS

Cases of female pelvic EES diagnosed and treated at our hospital between June 2009 and June 2019 were included in this study. Pathology data and ultrasound manifestations were assessed retrospectively to summarize the clinical traits and ultrasound features of female reproductive system EES. Based on the results, recommendations for the ultrasonography-based diagnosis of this disease were proposed.

RESULTS

During the 10-year study period, 13 female patients were diagnosed with EES in the pelvic cavity based on the results of postoperative pathology tests. The age of the patients ranged from 8 mouth to 40 years, and no patients demonstrated specific clinical symptoms. However, an examination of tumor biomarkers revealed that certain patients had elevated levels of CA125. In the 13 patients, 19 lesions were identified, including 16 that involved the reproductive system. The primary ultrasound manifestation was uneven, low-echo solidity or cystic solidity, exhibiting large size, irregular shape, and unclear boundary. A few patients had concurrent ascites. Although some lesions lacked blood supply, the blood supply of most lesions was medium to abundant, and the blood flow was mostly characterized by low resistant. Almost none of the lesions were definitively diagnosed preoperatively.

CONCLUSIONS

Preoperative definitive diagnosis of EES in the female reproductive system remains a great clinical challenge. Although certain clinical traits and ultrasound features are associated with this disease, and color Doppler ultrasonography might provide vital information indicating the presence of EES, the final diagnosis still depends on the pathological test results of the patients.

Environmental conditions in maternity wards: Evidence from rural healthcare facilities in 14 low- and middle-income countries

Adequate environmental conditions, comprising sufficient environmental hygiene items (e.g. gloves, soap, and disinfectant), adequate infrastructure (e.g. sanitation facilities, water supply), a clean environment, and hygienic behaviors in healthcare facilities (HCFs) are necessary for safe care in maternity wards. Few data are available describing environmental conditions in maternity wards in rural areas of low- and middle-income countries (LMICs). We collected data on these conditions from 1547 HCFs with maternity wards in 14 countries (Ethiopia, Ghana, Honduras, India, Kenya, Malawi, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe). We described patterns and availability of essential environmental conditions, and a regression model was developed to explore predictive factors. 73% of HCFs offering maternal and neonatal health (MNH) services did not meet the guidelines for the World Health Organization 'six cleans' (clean perineum, clean bed surface, clean hands, clean blade, clean cord tie, and clean towels to wrap the baby and mother). The items with the lowest availability were clean towels (40%). In a multivariable logistic regression model, HCFs that provided maternity services were more likely to have all 'six cleans' available if they: had at least an improved water source; had an infection prevention and control (IPC) protocol; had a budget considered sufficient that included funding for water, sanitation, hygiene, and IPC; and emphasized the importance of IPC within the nearby community. Our results demonstrate substantial differences between countries in the availability of environmental hygiene items, facility cleanliness, and quality of environmental health infrastructure in HCF maternity wards. There are several low-cost, high-impact, context-relevant opportunities to enhance essential environmental conditions that would improve the quality of neonatal and maternal care in maternity wards in HCFs in LMICs.

When People You Love Are The Unintended Consequences Of Opioid Policy

After the release of federal guidelines to curb opioid misuse, a patient is unable to obtain effective pain treatment and dies from complications.

Practicing precision medicine with intelligently integrative clinical and multi-omics data analysis

Precision medicine aims to empower clinicians to predict the most appropriate course of action for patients with complex diseases like cancer, diabetes, cardiomyopathy, and COVID-19. With a progressive interpretation of the clinical, molecular, and genomic factors at play in diseases, more effective and personalized medical treatments are anticipated for many disorders. Understanding patient’s metabolomics and genetic make-up in conjunction with clinical data will significantly lead to determining predisposition, diagnostic, prognostic, and predictive biomarkers and paths ultimately providing optimal and personalized care for diverse, and targeted chronic and acute diseases. In clinical settings, we need to timely model clinical and multi-omics data to find statistical patterns across millions of features to identify underlying biologic pathways, modifiable risk factors, and actionable information that support early detection and prevention of complex disorders, and development of new therapies for better patient care. It is important to calculate quantitative phenotype measurements, evaluate variants in unique genes and interpret using ACMG guidelines, find frequency of pathogenic and likely pathogenic variants without disease indicators, and observe autosomal recessive carriers with a phenotype manifestation in metabolome. Next, ensuring security to reconcile noise, we need to build and train machine-learning prognostic models to meaningfully process multisource heterogeneous data to identify high-risk rare variants and make medically relevant predictions. The goal, today, is to facilitate implementation of mainstream precision medicine to improve the traditional symptom-driven practice of medicine, and allow earlier interventions using predictive diagnostics and tailoring better-personalized treatments. We strongly recommend automated implementation of cutting-edge technologies, utilizing machine learning (ML) and artificial intelligence (AI) approaches for the multimodal data aggregation, multifactor examination, development of knowledgebase of clinical predictors for decision support, and best strategies for dealing with relevant ethical issues.

Perceptions towards Use of Electronic Dental Record at a Dental College, University of Hail, Kingdom of Saudi Arabia

AIM

This study highlights the use of electronic dental record (EDR) of a dental college at the University of Hail. This study has examined the perceptions of the stakeholders in regard to the objective mentioned above.

MATERIALS AND METHODS

It was a cross-sectional survey. The present study collected data from participants working in the dental clinics at the University of Hail. Face- and content-validated questionnaire was used as a study tool. The data were displayed in numbers and percentages. A Chi-squared test was used to measure the statistical significance. The p value < 0.05 was considered significant.

RESULTS

There were 166 respondents, out of which 92 (55.4%) were male and 74 (44.6%) were female participants. A highly significant result recorded for age group and rank/position for a variable that says using EDR will add to the skills of the dentists. Results showed that using EDR would not slow down the work. A need for a comprehensive training and the interference with the performance of dentists found as two main barriers towards the use of EDR.

CONCLUSION

This study has pioneered the idea of checking on the perceptions of stakeholders to enquire about the use of EDR in clinics in the Kingdom of Saudi Arabia. It has been reiterated by all the participants that EDR is a need for the clinics in the kingdom but some have reservations about the tedious nature of its use while some were worried about the excessive training they will need to overcome the difficulty of using it. It is observed from the stakeholders' replies that the use of EDR will slow down the work nature in clinics.

CLINICAL SIGNIFICANCE

The EDR is commonly used in many developed countries. The proficiency of its use is quite acceptable. The use of EDR in Kingdom of Saudi Arabia is relatively new. The present study measures the perception of its easiness and efficiency in dental practice.

Epidemiological and clinical characteristics of the first 557 successive patients with COVID-19 in Pernambuco state, Northeast Brazil

Background

South America is the current epicenter of COVID-19 pandemic. Yet, the epidemiological and clinical features of the disease have not been described in Brazil, the third most affected country in the world.

Methods

In this retrospective study, we describe the demographics, epidemiology and clinical features of the first 557 consecutive patients positive for SARS-CoV-2 living in Pernambuco state, Northeast Brazil.

Results

The first COVID-19 cases occurred in the high income population. The age of infected patients ranged from 27 days to 97 years with a median of 47 years. The ratio of males to female in the SARS-CoV-2-infected group was 0.83:1. The most common symptom was cough (74.51%), followed by fever (66.79%), dyspnea (56.01%), sore throat (28.19%) and O₂ saturation <95% (24.42%). 86.44% of the lethal cases were patients older than 51 years. The median time from illness onset to diagnosis was 4.0 days (range 0–39 days) Severe patients diagnosed after 14 days of symptoms onset had higher viral load than patients with mild disease.

Conclusions

Our study provides important information about COVID-19 in the tropics and will assist physicians and health officials to face the current pandemics as SARS-CoV-2 continues to spread in the human population.

•

We describe for the first time the demographics, epidemiology and clinical of COVID-19 in Brazil. .

•

The first COVID-19 cases occurred in the high income population.

•

86.44% of the lethal cases were patients older than 51 years.

•

Severe patients diagnosed after 14 days of symptoms onset had higher viral load than patients with mild disease.

Protecting Access To Abortion During The COVID-19 Pandemic

Several states attempted to deem abortions nonessential during the COVID-19 pandemic, leaving some women with difficult choices.

Community Workers Lend Human Connection To COVID-19 Response

Systems are investing in workers who come from the communities they serve to meet patient needs that extend well beyond clinic walls.

For LGBTQ Patients, High-Quality Care In A Welcoming Environment

Outside major urban centers, LGBTQ patients often travel hours to find trusted clinicians. One Iowa clinic has created a safe space just down the road.

A Descriptive Study of United States-Based Human Trafficking Specialty Clinics

Human trafficking is a crime associated with serious adverse health and mental health outcomes. It has been estimated that more than 40 million people worldwide have been victimized, which has resulted in high rates of traumatic injuries, unwanted and high-risk pregnancies, mental illness, substance use disorders; and suicidality among trafficked persons. Little is known as to what models of health care delivery are best in engaging and sustaining the involvement of trafficked individuals with health care and trafficked individuals have reported discouragement and/or re-traumatization as a result of inadequate or fragmented care. To address the gap in knowledge regarding best practices for engaging and sustaining trafficked patients with health care, the authors of this study set out to identify and describe medical and mental health specialty clinics that work exclusively with trafficked adults, with the goal of assisting organizations and health care providers in program development and to improve clinical outcomes. A patient-centered, comprehensive, interdisciplinary, and trauma informed approach to clinical care is recommended for the treatment of trafficked patients. The authors strongly suggest that human trafficking specialty clinics prioritize psychiatric care and mental health services given the high rate of trauma and mental health issues among trafficked persons.

Pilot Test of Connecting Pregnant Women who Smoke to Short Message Service (SMS) Support Texts for Cessation

INTRODUCTION

Most pregnant women know that smoking poses serious risks to baby and mother, yet many still smoke. We conducted a large randomized controlled trial and found that an SMS text-delivered program helped about 10% of these women quit smoking. In this paper, we describe the feasibility of disseminating a text-based intervention to pregnant women who smoke.

METHODS

We tested dissemination in two ways from prenatal clinics and compared recruitment rates to those found in our large randomized controlled trial. The first method involved "direct texting" where study staff identified women who smoked and sent them a text asking them to text back if they wanted to receive texts to help them quit. The second involved "nurse screening" where clinic staff from county health departments screened women for smoking and asked them to send a text to the system if they wanted to learn more about the program. Our primary outcome was feasibility assessed by the number of women who texted back their baby's due date, which served as "enrolling" in the texting program, which we compared to the recruitment rate we found in our large trial.

RESULTS

Over 4 months, we texted 91 women from the academic health system. Of those, 17 texted back and were counted as "enrolled." In the health departments, across the 4 months, 12 women texted the system initially. Of those, 10 were enrolled. This rate was similar to the rate enrolled in the randomized controlled trial.

DISCUSSION

Two different methods connected pregnant women who smoke to a texting program. One of these methods can be automated further and have the potential of helping many women quit smoking with minimal effort. Clinical Trial # NCT01995097.

Which Factors Determine Affected Sites in Hidradenitis Suppurativa?

BACKGROUND

The factors that determine whether an area of the body will be affected by hidradenitis suppurativa (HS) are unknown.

METHODS

To address these factors, we performed multivariate regression analyses in a cohort of 1,138 patients.

RESULTS

We found that the body sites affected occurred in specific combinations that were influenced by sex and body mass index. We also revealed unexpected correlations between some sites and other comorbidities such as inflammatory diseases, acne conglobata, or dissecting folliculitis of the scalp.

CONCLUSION

Such correlations are crucial to unravel a disease as variable as HS and identify pathophysiological mechanisms to enable the provision of personalized management.

After Prison, Healthy Lives Built On Access To Care And Community

A North Carolina program helps recently released inmates connect to health care, social services, and support.

Factors influencing the confidence and knowledge of nurses prescribing antiretroviral treatment in a rural and urban district in the Western Cape province

Background

Since the introduction of nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa in 2010, initiation of antiretroviral therapy (ART) in primary care has become the responsibility of nurses. The continued success of this approach is dependent on factors such as adequate training and effective support systems.

Objectives

This study aimed to investigate factors influencing the knowledge and confidence of professional nurses in managing patients living with human immunodeficiency virus (HIV) in primary healthcare settings in a rural and urban district in the Western Cape.

Methods

A cross-sectional survey was conducted amongst 77 NIMART-trained nurses from 29 healthcare facilities to measure demographic details, influencing factors, HIV management confidence and HIV management knowledge.

Results

The majority of participants had adequate HIV management knowledge and reported being very confident or expert in the HIV management skills or competencies. Participants trained recently on local guidelines (Practical Approach to Care Kit) (3 years ago or less) had significantly higher knowledge scores. Regular feedback about clinic and personal performance was associated with higher HIV management knowledge. Participants who received NIMART mentoring over a period of 2 weeks had a higher mean confidence score compared to other periods of mentoring. A higher caseload of patients living with HIV was also associated with higher knowledge and confidence.

Conclusion

Training, mentorship and clinical practice experience are associated with knowledge and confidence. Recommendations include the strengthening of current training and mentoring and ensuring that NIMART-trained nurses are provided with regular updates and sufficient opportunities for clinical practice.

University hospitals, general hospitals, private clinics: Place-based differences in patient characteristics and outcomes of AF-A SAKURA AF Registry Substudy

BACKGROUND

Relations between characteristics and outcomes of patients in Japan with atrial fibrillation (AF) and the type of medical facility providing their outpatient care are unclear.

METHODS AND RESULTS

We compared patient characteristics and outcomes between 2 university hospitals (n=1178), 20 general hospitals (n=1308), and 41 private clinics (n=751) (follow-up: 39.3 months) in the prospective SAKURA AF Registry. Private clinic patients were significantly older than university hospital and general hospital patients (73.4±9.2 vs. 70.3±9.8 and 72.6±8.9 years; p<0.001), and these patients' CHADS₂ scores were significantly lower than general hospital, but higher than university hospital patients (1.8±1.1 vs. 2.0±1.2 and 1.6±1.1; p<0.001). The Kaplan-Meier incidences of stroke/systemic embolism (SE) (1.72 vs. 1.58 vs. 0.84 events per 100 patient-years; p=0.120), a cardiovascular event (4.09 vs. 2.44 vs. 1.40; p<0.001), and death were higher (2.39 vs. 2.21 vs. 1.24; p=0.015) for university and general hospital patients than for private clinic patients; the incidences of major bleeding were equivalent (1.78 vs. 1.33 vs. 1.16; p=0.273). After multivariate adjustments, this trend persisted.

CONCLUSIONS

Adverse clinical events at small to large hospitals appear to be higher than those at private clinics, suggesting that careful attention for preventing stroke/SE and cardiovascular events should be paid to patients at a university or general hospital.

Special problems associated with reprocessing instruments in outpatient care facilities: Physical spaces, education, infection preventionists, industry, reflections

The infection preventionists' (IPs') presence and intervention in outpatient facilities continues to lag behind the inpatient hospital IPs' presence. Additionally, in an outpatient world that is heavy on instrument reprocessing, IPs must be prepared to assess instrument reprocessing practices, including high-level disinfection and sterilization to keep our patients and staffs safe. This paper presents 3 problems associated with instrument reprocessing practices in health care facilities, with a special emphasis on outpatient facilities: physical space problems, training and education problems, and lack of IPs' presence. We offer solutions and mitigation strategies for these 3 problems. We also give some reflections on the current state of IP presence and responsibilities, and industry responsibilities, and we call for robust partnerships between IPs and the instrument reprocessing industry.

The Role of Clinics in Determining Older Recent Immigrants' Use of Health Services

Immigrants are ineligible for federally-funded Medicaid in the U.S. until at least 5 years after arrival. There is little information on where they receive care in light of this restriction. Using Blinder-Oaxaca decomposition, this study examines whether the setting in which older recent immigrants receive care (i.e., health clinic, emergency room or doctor's office) explains delays in care. Among older adults with a usual source of care, 13.5% of recent immigrants had not seen a health professional in the past year compared to 8.6% of non-recent immigrants and 6.3% of native-born. Approximately 23% of these differences is attributable to recent immigrants' tendency to receive care in clinics and community health centers. Even when older recent immigrants manage to find a usual source of care, it is of lower quality than that received by their non-recent immigrant and native-born counterparts.

Pediatric Urgent Care-New and Evolving Paradigms of Acute Care

Parents of pediatric patients seek appropriate high-quality care in a timely, cost-effective, and convenient manner. Pediatric urgent care offers a new and evolving delivery model that serves a growing demand by complementing services provided by the medical home and by pediatric emergency departments. Pediatric urgent care services are used by both nonprofit and for-profit sectors and include hospital and satellite clinics, free-standing clinics, retail-based clinics, and telemedicine services. The clinical scope is variable and there are distinct and unique operational considerations. Training models are evolving and further research is warranted.

Comparison of patient flow and provider efficiency of two delivery strategies for HPV-based cervical cancer screening in Western Kenya: a time and motion study

Background: Improving patient flow and reducing over-crowding can improve quality, promptness of care, and patient satisfaction. Given low utilization of preventive care in low-resource countries, improved patient flows are especially important in these settings.

Objective: Compare patient flow and provider efficiency between two cervical cancer screening strategies via self-collected human papillomavirus (HPV).

Methods: We collected time and motion data for patients screened for cervical cancer in 12 communities in rural Migori County, Kenya as part of a larger cluster randomized trial. Six communities were randomized to screening in community health campaigns (CHCs) and six to screening at government clinics. We quantified patient flow: duration spent on each active stage of screening and wait times, and the number of patients arriving at CHCs and clinics each hour of the day. In addition, for four CHCs, we collected time and motion data for providers, and measured provider efficiency as a ratio of active (service delivery) time to total time spent at the clinic.

Results: Total duration of screening visits, at CHCs and clinics was 42 and 87 minutes, respectively (p < 0.001 for difference). Total active time lasted longer at CHCs, with a mean of 28 minutes per patient versus 15 minutes at clinics, largely due to differences in duration for group education (p < 0.001). Wait time for registration at clinics was 36 minutes, explaining most of the difference between settings, but sometimes incorporated other health services.

Conclusions: There is a substantial difference in patient flow at clinics compared to CHCs. Shorter duration at CHCs suggests that the model is favorable for patients in limiting time spent on screening. Future cervical cancer screening programs designed for scale-up should consider how this advantage may enhance satisfaction and uptake. For clinic-based screening programs, efforts could be made towards reducing registration wait times.

Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities

Safe environmental conditions and the availability of standard precaution items are important to prevent and treat infection in health care facilities (HCFs) and to achieve Sustainable Development Goal (SDG) targets for health and water, sanitation, and hygiene. Baseline coverage estimates for HCFs have yet to be formed for the SDGs; and there is little evidence describing inequalities in coverage. To address this, we produced the first coverage estimates of environmental conditions and standard precaution items in HCFs in low- and middle-income countries (LMICs); and explored factors associated with low coverage. Data from monitoring reports and peer-reviewed literature were systematically compiled; and information on conditions, service levels, and inequalities tabulated. We used logistic regression to identify factors associated with low coverage. Data for 21 indicators of environmental conditions and standard precaution items were compiled from 78 LMICs which were representative of 129,557 HCFs. 50% of HCFs lack piped water, 33% lack improved sanitation, 39% lack handwashing soap, 39% lack adequate infectious waste disposal, 73% lack sterilization equipment, and 59% lack reliable energy services. Using nationally representative data from six countries, 2% of HCFs provide all four of water, sanitation, hygiene, and waste management services. Statistically significant inequalities in coverage exist between HCFs by: urban-rural setting, managing authority, facility type, and sub-national administrative unit. We identified important, previously undocumented inequalities and environmental health challenges faced by HCFs in LMICs. The information and analyses provide evidence for those engaged in improving HCF conditions to develop evidence-based policies and efficient programs, enhance service delivery systems, and make better use of available resources.

SIAMOC position paper on gait analysis in clinical practice: General requirements, methods and appropriateness. Results of an Italian consensus conference

Gait analysis is recognized as a useful assessment tool in the field of human movement research. However, doubts remain on its real effectiveness as a clinical tool, i.e. on its capability to change the diagnostic-therapeutic practice. In particular, the conditions in which evidence of a favorable cost-benefit ratio is found and the methodology for properly conducting and interpreting the exam are not identified clearly. To provide guidelines for the use of Gait Analysis in the context of rehabilitation medicine, SIAMOC (the Italian Society of Clinical Movement Analysis) promoted a National Consensus Conference which was held in Bologna on September 14th, 2013. The resulting recommendations were the result of a three-stage process entailing i) the preparation of working documents on specific open issues, ii) the holding of the consensus meeting, and iii) the drafting of consensus statements by an external Jury. The statements were formulated based on scientific evidence or experts' opinion, when the quality/quantity of the relevant literature was deemed insufficient. The aim of this work is to disseminate the consensus statements. These are divided into 13 questions grouped in three areas of interest: 1) General requirements and management, 2) Methodological and instrumental issues, and 3) Scientific evidence and clinical appropriateness. SIAMOC hopes that this document will contribute to improve clinical practice and help promoting further research in the field.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics

Purpose of review

To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.

Sources of information

The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).

Findings

The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.

Limitations

The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.

Implications

Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

[Myeloradiculitis due to Schistosoma haematobium: about an observation in Dakar (Senegal)]

Nervous localisations of schistosomiasis are rare. We report the case of a 25 year-old Senegalese patient admitted for a progressive myeloradiculitis onset, over a one week period. The diagnosis of Schistosoma haematobium myeloradiculitis was made in front of a positive serum serology for S. haematobium, presence of S. haematobium eggs in urine, hyperproteinorachia, endemicity of S. haematobium in the region where the patient was originating and a past medical history of macroscopic hematuria in a context of river bathing. There was also no arguments for another cause to these neurological manifestations. Our patient was treated with praziquantel, prednisone and physiotherapy. Evolution was marked 6 weeks after the beginning of treatment by a significant improvement of motor deficit, enabling the patient to walk again. There was also a regression of genitosphincter dysfunction. Work-up for patients presenting with paraplegia in tropical countries, should also include search for S. heamatobium infection.

Legal Care as Part of Health Care: The Benefits of Medical-Legal Partnership

Many of the social determinants of health are rooted in legal problems. Medical-legal partnerships (MLPs) have the potential to positively change clinical systems. This change can be accomplished by integrating legal staff into health care clinics to educate staff and residents on social determinants of health and their legal origins. When the MLP team works directly with patients to identify and address legal needs that improve health outcomes, and incorporate legal insights and solutions into health care practice where the patient population is overwhelmingly impacted by social conditions, outcomes are beneficial to children and families.

Translating orthopaedic basic science into clinical relevance

In orthopaedic and trauma surgery, the rapid evolution of biomedical research has fundamentally changed the perception of the musculoskeletal system. Here, the rigor of basic science and the art of musculoskeletal surgery have come together to create a new discipline -experimental orthopaedics- that holds great promise for the causative cure of many orthopaedic conditions. The Journal of Experimental Orthopaedics intends to bridge the gap between orthopaedic basic science and clinical relevance, to allow for a fruitful clinical translation of excellent and important investigations in the field of the entire musculoskeletal system.

Hepatitis B vaccination among primary health care workers in Northwest Pakistan

BACKGROUND

We assessed hepatitis B vaccination and its determinants among health care workers (HCW) in rural Northwest Pakistan.

METHODS

This cross sectional study was conducted among 485 HCWs from both public and private clinics. Data about hepatitis B vaccination, socio-demographic, knowledge regarding modes of transmission of hepatitis B virus, perceived disease severity and benefits of vaccination was collected through questionnaire. Multivariable logistic regression analysis was performed.

RESULTS

Prevalence of complete hepatitis B vaccination was 40% (among Physicians with MBBS/MD qualification; 86% and lowest among non-qualified Dispensers;16%). Also, prevalence was higher among HCWs from public Dispensaries (77%) than those working in private clinics (35%). Being MBBS/MD Physician (Adj. OR 26.60; 95%CI 9.27-73.23), Non-MBBS/MD Physician (Adj.OR 1.89; 95%CI 0.78-4.59), qualified Dispensers (Adj. OR 3.58; 95%CI 1.34-9.54) compared to non-qualified Dispensers, working in public clinics (Adj. OR 2.54; 95%CI 1.13-5.69) as compared to private, perceived disease threat after exposure to blood and body fluids (Adj. OR 1.11; 95%CI 1.03-1.19) and perceived benefits of hepatitis B vaccination (Adj. OR 1.13; 95%CI 1.09-1.19) were significant predictors of complete hepatitis B vaccination.

CONCLUSION

Improved perception of disease threat and benefits of vaccination and qualification of HCWs are associated with hepatitis B vaccination among Primary HCWs.