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OBJECTIVES: Following the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and the subsequent global spread of the 2019 novel coronavirus disease (COVID-19), health systems and the populations who use them have faced unprecedented challenges. We aimed to measure the impact of COVID-19 on the uptake of hospital-based care at a national level. DESIGN: The study period (weeks ending 5 January to 28 June 2020) encompassed the pandemic announcement by the World Health Organization and the initiation of the UK lockdown. We undertook an interrupted time-series analysis to evaluate the impact of these events on hospital services at a national level and across demographics, clinical specialties and National Health Service Health Boards. SETTING: Scotland, UK. PARTICIPANTS: Patients receiving hospital care from National Health Service Scotland. MAIN OUTCOME MEASURES: Accident and emergency (A&E) attendances, and emergency and planned hospital admissions measured using the relative change of weekly counts in 2020 to the averaged counts for equivalent weeks in 2018 and 2019. RESULTS: Before the pandemic announcement, the uptake of hospital care was largely consistent with historical levels. This was followed by sharp drops in all outcomes until UK lockdown, where activity began to steadily increase. This time-period saw an average reduction of −40.7% (95% confidence interval [CI]: −47.7 to −33.7) in A&E attendances, −25.8% (95% CI: −31.1 to −20.4) in emergency hospital admissions and −60.9% (95% CI: −66.1 to −55.7) in planned hospital admissions, in comparison to the 2018–2019 averages. All subgroup trends were broadly consistent within outcomes, but with notable variations across age groups, specialties and geography. CONCLUSIONS: COVID-19 has had a profoundly disruptive impact on hospital-based care across National Health Service Scotland. This has likely led to an adverse effect on non-COVID-19-related illnesses, increasing the possibility of potentially avoidable morbidity and mortality. Further research is required to elucidate these impacts.

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer.Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016.We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis.We identified Medicare beneficiaries65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250).From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc.The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Introduction Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. Aims and Methods Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021–2022. Results Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). Conclusions With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. Implications This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient's capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

Introduction This study aimed, first, to audit the appropriateness of surgical referrals to an acute surgical unit for urgent assessment and, second, to devise a screening tool for use in the emergency department to categorise patients into those who need an urgent surgical review and those who can be seen in an ambulatory setting within the next few days. Methods The first phase of the study was an audit of surgical referrals between 1 and 18 February 2020 to check the appropriateness of the surgical referral. In the second phase, a tool was designed to screen patients who did not require urgent surgical review and could be seen in the ambulatory clinic. A prospective questionnaire study was conducted from 1 February to 24 March 2020 with patients who were admitted to an acute surgical ward. Based on responses to the screening tool, patients were given the outcome of whether they can be discharged and seen in an ambulatory clinic. The accuracy of the screening tool outcome was assessed and compared with actual patient discharge outcomes by the surgical team evaluating patients’ electronic medical records. Results In the first audit of referrals to the acute surgical ward, 206 patients were referred to the acute surgical unit and seen by the senior surgeon. Of these, 142 (68.9%) were discharged on the same day with or without follow-up in the ambulatory surgical clinic. In the prospective questionnaire phase of the study, 98 patients completed the questionnaire. The most common presentation was abdominal pain (n=60) followed by urological symptoms (n=11), symptoms of hernia complication (n=10), abscess (n=7), testicular pain (n=2) and trauma (n=2). Of the patients discharged on the same day, 50% were given ambulatory care appointments and 50% were discharged with no further follow-up. The sensitivity and specificity of the screening tool were 100% and 60.7%, respectively; the overall accuracy was 88.4%. Conclusion A large proportion of patients who are referred to the acute surgical unit can be deferred and seen in the ambulatory clinic. The screening tool used for acute surgical referral had reasonable sensitivity and high specificity to screen patients who can be seen in ambulatory clinics. At the same time, it identified patients who were unwell and required urgent surgical admission.

This study was conducted to investigate the types of conversational agents (CA) that can help address questions and concerns ("lay topics" [LTs]).We analyzed audio recordings of telephone consultations with 100 breast cancer patients and their families. (1) We identified the content and mode of expression of LTs about breast cancer raised during actual telephone consultations. (2) We checked for the presence of clue information (CI) that can help patients resolve their LTs.None of the 805 LTs of the 100 callers were the same. Treatment-related questions occurred in 70 of the 100 consultations. CIs were present in 52.5% of the LTs.The results suggest that chatbots (a type of CA) that offer CIs are more feasible than chatbots that answer each question directly in cancer consultations. Moreover, it is difficult to answer questions directly because preparing answers to all LTs in a breast cancer consultation is challenging owing to LT differences. Therefore, preparing high-quality CIs focused on treatments is required.An increasing number of cancer patients are seeking information to resolve their LTs. CAs can help supplement the limited human resources available if they are supplied with appropriate CIs.

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

PURPOSE: Patients with cancer are at heightened risk of experiencing financial hardship. Financial navigation (FN) is an evidence-based approach for identifying and addressing patient and caregiver financial needs. In preparation for the implementation of a multisite FN intervention, we describe existing processes (ie, events and actions) and mechanisms (ie, how events work together) connecting patients to financial assistance, comparing rural and nonrural practices. METHODS: We conducted in-depth, semistructured interviews with stakeholders (ie, administrators, providers, and staff) at each of the 10 oncology care sites across a single state (five rural and five nonrural practices). We developed process maps for each site and analyzed stakeholder perspectives using thematic analysis. After reporting findings back to stakeholders, we synthesized themes and process maps across rural and nonrural sites separately. RESULTS: Eighty-three stakeholders were interviewed. We identified six core elements of existing financial assistance processes across all sites: distress screening (including financial concerns), referrals, resource connection points, and pharmaceutical, insurance, and community/foundation resources. Processes differed by rurality; however, facilitators and barriers to identifying and addressing patient financial needs were consistent. Open communication between staff, providers, patients, and caregivers was a primary facilitator. Barriers included insufficient staff resources, challenges in routinely identifying needs, inadequate preparation of patients for anticipated medical costs, and limited tracking of resource availability and eligibility. CONCLUSION: This study identified a clear need for systematic implementation of oncology FN to equitably address patient and caregiver financial hardship. Results have informed our current efforts to implement a multisite FN intervention, which involves comprehensive financial toxicity screening and systematization of intake and referrals.

Background Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons. Methods We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care. Results Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team. Conclusions Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.

In the seven years since the HIV Organ Policy Equity (HOPE) Act made HIV-positive organ donation to HIV-positive recipients legally permissible in the United States, there have been fewer HIV-positive organ donations than expected. Organ procurement organizations (OPOs) play a key role in the transplant system and barriers at OPOs may be partly responsible for the relatively low number of HIV-positive donors. To understand potential OPO barriers, we conducted semi-structured interviews with 20 OPO staff members. Interviews were recorded, transcribed, and analyzed using a conventional content analytic approach with two coders. OPO staff had high levels of knowledge about HOPE. Many had evaluated referrals of HIV-positive donors and approached families for authorization. Barriers to HIV-positive organ recovery identified included obtaining authorization for donation, potentially disclosing HIV status to next-of-kin, and fear of HIV infection among those engaged in organ recovery. Strategies to overcome these barriers include providing continuing education about the specific tasks required to procure organs from HIV-positive donors, implementing targeted interventions to reduce fear of infection, and developing partnerships with HIV advocacy and care organizations. Given the central role OPOs play, HIV-positive donations are unlikely to occur in significant numbers unless these barriers can be overcome.

In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military.Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research.Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings.Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications.

ObjectivesTo describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center.Study designWe reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications.ResultsOf 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n=50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10>50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14±10mL. Of the 10patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration.ConclusionsPatients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment.ImplicationsUltrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.

BackgroundRecent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices.MethodsIn this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation).ResultsAmong the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist.ConclusionOur findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.

The article presents the age-sex structure of people who have suffered severe traumatic brain injury on the example of a municipal medical organization providing medical care and medical rehabilitation in outpatient settings. The high prevalence of this type of injury among males of working age has been established. The duration of temporary disability and the timing of referral of this category of people for medical and social examination are reflected. There is a high level of disability among people who have suffered severe traumatic brain injury, and in most cases they are assigned more severe first and second disability groups. The article reflects the personnel problems of a municipal medical organization providing outpatient medical care in the formation of a multidisciplinary rehabilitation team, which require their resolution at the regional level.

Aims: To describe the aetiology and microbial susceptibility profile of endophthalmitis cases treated at an ophthalmological referral centre in Colombia. Material and Methods: A retrospective descriptive study was carried out with all endophthalmitis cases referred to the Fundación Oftalmológica de Santander FOSCAL (Floridablanca, Colombia) from 1 January 2012 to 31 December 2015. Results: 121 eyes of 121 patients were evaluated. 77.7% of them were male and the mean age was 42.9 years. Five of them (4.1%) corresponded to endogenous endophthalmitis, and 116 (95.9%) to exogenous endophthalmitis. Of the latter, 66.9% were associated with trauma (almost one-half of them associated with intraocular foreign body), and 29.5% with intraocular surgery. The most common isolated microorganisms in the exogenous endophthalmitis group corresponded to methicillin-resistant and methicillin-sensitive strains of Staphylococcus epidermidis and Staphylococcus aureus, which were mostly susceptible to imipenem, vancomycin and moxifloxacin and resistant to ceftazidime. Conclusion: Endophthalmitis is a potentially sight-threatening condition, especially in cases of inadequate treatment. Therefore, antimicrobial therapy should be guided by vitreous humour culture to assure that the causative microorganism is susceptible to the selected agent. The results of our study lead us to propose vancomycin, moxifloxacin or imipenem as first-line antimicrobial options.

OBJECTIVE: To identify barriers to, describe the development of and evaluate the implementation of a behavioural theory informed strategy to improve staff personal protective equipment (PPE) compliance during COVID-19 in a regional Australian Emergency Department. METHODS: Barriers to PPE use were identified through staff consultation then categorised using the Theoretical Domains Framework. The Behaviour Change Wheel was used to develop a strategy to address the barriers to PPE compliance. The strategy was refined and endorsed by the site COVID taskforce. Data were collected through direct observation. Descriptive statistics were used to summarise PPE compliance and inductive content analysis for free text data of staff behaviours. RESULTS: 73 barriers were identified, mapped to 9 intervention functions and 42 behaviour change techniques. The predominant mechanisms were: (1) Executive communication reinforcing policy and consequences; (2) implementation of a PPE Marshal; (3) face to face reinforcement / modeling; (4) environmental restructuring including electronic medical record modifications. The PPE Marshal observed 281 PPE activities. PPE compliance varied between 47.9% (Buddy check) and 91.8% (Bare below elbow). The PPE Marshal intervened on 121 occasions, predominantly through buddying, explaining and demonstrating correct PPE use, most frequently with medical staff (72%). CONCLUSION: We describe an evidence-based process to overcome barriers to PPE compliance that maximize safe work practice in a time critical situation. Staff require enabling, access to equipment and reinforcement to use PPE correctly.

Background Even though patient engagement in the pharmacy encounter is low, few studies focus on activating patients. A Question Prompt List (QPL) has been used successfully in other parts of healthcare to encourage patients to raise their questions and concerns. For a QPL to be useful in a pharmacy setting, it first must be considered valuable and be accepted by pharmacists. Objective To investigate the experience of community pharmacists using a QPL in counseling patients about prescribed medications. Methods An explorative, qualitative study was conducted in 2020. A QPL, for use in pharmacy counseling, was developed based on previous literature. Semi-structured interviews were held with pharmacists. A thematic analysis approach was conducted, and the analytical framework Technology Acceptance Model (TAM) was used. Results Data were collected in 7 Swedish community pharmacies in interviews with 29 purposefully selected pharmacists. Three themes were identified: Perceived usefulness: the impact of the QPL on patient activation in the encounter, Perceived ease of use of the QPL in pharmacies, and Increasing the perceived usefulness and ease of use of the QPL. The pharmacists perceived patients as more active in the meeting when using the QPL. The list focused the conversation on medications, which the pharmacists appreciated from a professional point of view. They described the QPL as a useful tool that could easily be integrated into the dispensing process and required little training; however, challenges described were, for example, time constraints and stress. Conclusions Pharmacists reported that using a QPL improved patient participation in the encounter. Encouraging counseling on medications was seen as beneficial from a professional point of view. In the early adoption phase, the QPL was easy to implement and did not increase the pharmacists' workload. A QPL appears to be a promising tool for pharmacists to improve the quality of the consultation experience.

Advanced heart failure (HF) therapies improve survival in patients with stage D HF. We sought to evaluate differences by race/ethnicity and sex in advanced HF therapy referrals and decision-making across a multicenter survey. We performed a retrospective analysis of patients referred for evaluation for advanced HF therapies at 9 centers (n = 515) across the United States. The median age was 58 years, and 73% were male. White patients comprised 55.7% of referrals, whereas non-White patients comprised 44.3%. Non-ischemic etiology was more common in non-White patients (66.6% vs 47.4% p = 0.0005), and ischemic etiology was more common in men (37.8% vs 20.4% p = 0.0005). The primary reason for referral differed by race/ethnicity but not sex, with ventricular arrhythmias (7.6% vs 3%, p = 0.024) and pulmonary hypertension (3.4% vs 0.4% p = 0.018) being more common in White patients, whereas worsening HF was less common (25.4% vs 35.9%; p = 0.009). White patients were offered left ventricular assist devices (LVADs) (60.3% vs 54.7 p = 0.039) and heart transplants (51.8% vs 33.1% p = 0.0007) more often than non-White patients. The preference not to pursue LVAD therapy was more common in non-White patients (17.6% vs 9.6%; p = 0.049). Men were more often declined for a heart transplant because of psychosocial contraindications (34% vs 15%, p = 0.005). In conclusion, in this multicenter analysis of referrals for advanced HF therapies, we observed significant differences by race, ethnicity, and sex in both referral characteristics and evaluation outcomes. Further investigation is warranted to better understand why rates of LVAD and transplantation may be lower in non-White patients who are referred for advanced therapies.

In the United States, a small proportion of potential deceased organ donor referrals lead to donation and recovery. Understanding variation in the processes involved between organ procurement organizations (OPOs) may help increase deceased donation and reduce the organ shortage. We studied 103 923 referrals from 10 OPOs from 2018 to 2019, of which 14.4% led to approach for authorization, 8.2% led to authorization, 5.1% led to organ recovery, and 4.8% led to transplantation. First-person authorization (FPA) was associated with threefold higher odds of donation (OR =

To describe rates of urology consultation following renal trauma and assess subsequent impact on imaging and intervention. Renal trauma may be initially managed by either trauma or urologic surgeons alone or collaboratively. Differences in management between the specialties are not well studied.We conducted an IRB-approved retrospective review of patients at a Level I trauma center sustaining renal trauma between 2014 and 2021. Demographic, injury, radiologic, and intervention variables were extracted. Frequencies and medians were compared using chi-squared and Fischer's exact tests or Mann-Whitney U tests, respectively. Analyses were performed using STATA with P.05 considered significant.From 2014 to 2021, 118 patients with median age 29 (IQR 22-41) sustained renal trauma. Urology was consulted in 18 (15.3%) cases. Demographic and injury characteristics were similar between the 2 groups. AAST renal injury grade was transcribed in the initial radiologic reports for 49 (41.5%) of patients. Those in the urology consult group were more likely to receive delayed contrast imaging during their admission (50.0% vs 17.0%, P.01). Among those with high-grade injuries, those with urology consult were less likely to undergo nephrectomy (36.4% vs 78.8%, P = .02).We observed differences in imaging patterns between renal trauma patients who are managed primarily by trauma surgery versus urology. However, the impact of these differences in imaging remains to be elucidated. Among patients with high-grade renal trauma, urology consult was associated with decreased rate of nephrectomy, emphasizing the feasibility of renal salvage in a multidisciplinary trauma setting.

The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure.Cohort study.37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012.KAS era (pre-KAS vs post-KAS).Referral for transplantation, start of transplant evaluation, and waitlisting.Multivariable time-dependent Cox models for the incident and prevalent population.Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred.Limited to 3 states, residual confounding.In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.

We assessed the number of referrals for low vision (LV) services to determine if establishing an LV program at a large academic medical center impacted referral rates. Visual acuity (VA), referral outcome, location, and specialty were examined as factors that could impact referrals.This study aimed to identify gaps in the referral process to LV services.Electronic medical records of patients were reviewed to ascertain the referral rate among those who qualified for services, both before (2014 to 2016) and after (2017 to 2019) the establishment of an LV program. The medical records were further subdivided into two categories based on VA in the better-seeing eye: 20/70 to 20/200 and 20/200 to worse vision.A total of 2014 patient records with VA qualifying for LV services were reviewed. The proportion of patients who had a VA of 20/70 to 20/200 inclusive in their better eye was 91.7%. A majority (89.8%) of patients with VA of 20/70 to 20/200 and 74.4% of patients with VA worse than 20/200 were never referred. Before establishing an LV program, only 2.2% of patients with VA of 20/70 to 20/200 were referred for services on their first visit, which improved to 8% after the program was established (odds ratio [OR], 3.88; 95% confidence interval [CI], 2.37 to 6.33; P.001). Also, before the program's establishment, 12.5% of patients with VA worse than 20/200 were referred on their first visit, which increased to 31.9% after the program's establishment (OR, 3.29; 95% CI, 1.50 to 7.19; P = .002). Patients with VA worse than 20/200 were more likely to be referred (before: OR, 6.34 [95% CI, 3.03 to 13.28; P.001]; after: OR, 5.38 [95% CI, 3.09 to 9.37; P.001]). Our data also showed that 10.3% of patients in this study declined referral to LV services.Referral rates to LV services are low among patients who qualify. The establishment of an LV program at the medical center significantly increased referral rates. However, more improvement is necessary to connect patients to LV services.

Purpose: The purpose of this article is to explore the clinical and neuroradiologic properties of atypical teratoid/rhabdoid tumors. Methods: Data from 6 pediatric patients with atypical teratoid/rhabdoid tumors, which mainly contained the features of magnetic resonance imaging (MRI) and positron emission tomography (PET)/computed tomography (CT), was retrospectively analyzed. Follow-up was conducted in all patients through clinic services and/or telephone consultation. Results: The patients included 4 males and 2 females, aged from 3.2 to 83.1 months at the initial diagnosis. All patients had MRI scans. Two patients underwent 18F-fluorodeoxyglucose PET/CT scintigraphy preoperatively and 4 postoperatively. All primary lesions were located in the cranial cavity and the average diameter of lesions was 37.2 mm. Cerebrospinal fluid spread on enhanced T1-weighted images were found in 2 patients. Multiple metastases were found on MRI and PET/CT scans, which were located at cranial cavity, spinal cord, lung and lymph node. The primary and metastatic lesions showed evident uptake of 18F-fluorodeoxyglucose. Two patients underwent total tumor removal, and 4 patients underwent subtotal removal. None of the patients received shunt surgery. Follow-up was performed in all 6 patients. One patient survived event-free 38.4 months after resection. The mean overall survival of the remaining 5 patients was 5.1 months. Conclusion: We identified specific PET/CT and MRI features that can facilitate the recognition of atypical teratoid/rhabdoid tumors prior to biopsy.

COVID-19 has led to an increased use of online consultations in occupational health. We examined experience, satisfaction, and difficulties with online consultations during the first year after the COVID-19 pandemic by surveying a sample of workers.An online survey was conducted in March 2021 among full-time employees of an online panel survey (E-COCO-J: The Employee Cohort Study on the COVID-19 Pandemic in Japan). Respondents were asked to report whether they had online or face-to-face consultations with occupational health professionals in the past year, their level of satisfaction, and their difficulties and problems related to the online consultations.Of the 1,153 respondents, 1,102 (excluding those who were unemployed or on leave) were included in the analysis. Fifty respondents had had online consultations in the past year and 57 had face-to-face consultations. The proportion of respondents who reported satisfaction with online consultations was high (more than 70%) for general health, follow-ups, and guidance consultations, among others. However, the proportion of satisfaction with online occupational consultations was low (less than 40%) for employees who worked long hours, or took leave or returned to work. Over 30% of the respondents indicated that the difficulties with online consultations were due to incongruence with their expectations ("I preferred a face-to-face consultation instead of an online one"), quality of communication ("I did not feel like I was able to consult sufficiently"), and concerns about confidentiality ("I was worried that someone could hear our conversation").The experience of online consultations was similar to that of face-to-face consultations. Satisfaction with online occupational consultations for those who worked long hours and those who took leave or returned to work was low. In the online consultation for occupational health, the occupational health professional may be required to judge its suitability depending on type of the consultation and take necessary consideration and measures to maintain the quality of the online consultation.

As Indonesia’s rifampin resistance testing rates are lower than global testing rates per the 2020 WHO global tuberculosis (TB) report, prevalence of multidrug-resistant TB may be underestimated. Our study aimed to evaluate prevalence and patterns of TB drug resistance (DR) within Indonesia. We conducted a cross-sectional analysis of baseline data collected from 2017–2018 as part of a cohort study of adults with presumed pulmonary TB at 7 DR-TB referral hospitals in Indonesia. Bacteriological examinations (acid-fast bacilli, GeneXpert, sputum culture) and drug-susceptibility testing were performed following the guidelines of the National TB Program. Of 447 participants with complete bacteriological examinations, 312 (69.8%) had positive sputum cultures for Mycobacterium tuberculosis. The proportion of MDR and pre-extensively drug-resistant was higher in previously treated compared with newly diagnosed participants (52.5% [73/139] versus 15% [26/173]). Compared with drug-sensitive case, drug-resistant TB was associated with cavities. Given the difference between rates of DR in TB referral hospitals from our study compared with the WHO survey in 2019 that showed 17.7% and 3.3% DR among previously treated and newly diagnosed participants globally, further characterization of Indonesia’s TB epidemiology in the general population is needed. Strategies, including public policies to optimize case finding, strengthen capacity for resistance testing, and prevent loss to follow-up will be critical to reduce the burden of TB in Indonesia.

There is an increasing burden of kidney diseases worldwide and access to specialist care is limited. Telemedicine, has been relatively less used in developing countries like India. The current study aims to assess the feasibility and acceptance of telenephrology services at our institute, a public hospital.A total of 150 patients were selected by stratified random sampling from the list of attendees who had undergone both in-person outpatient consultation and telenephrology consultation. Patient's attitude towards, and knowledge and acceptance of telenephrology services were evaluated.The average age of the study cohort was 42.52 ± 15.1 years. More than one-third (39.3%) of our patients belonged to the lower middle socioeconomic class. The median distance traveled to reach our outpatient clinic was 113.5 km (3-2249 km). Patients reported lost workdays in 54.7% cases. The majority (95%) of patients managed to consult through teleservices successfully. Ninety percent of the patients gave a satisfaction score of 4 (out of 5) or above for their tele-consultation experience. The most important perceived benefit of teleconsultation was the reduced risk of infection (40.6%) followed by economic benefits (32%). The major disadvantage (36%) was the absence of physical examination. A combination of physical and telenephrology services was the option preferred by 84% of the patients.In developing countries like India, with the majority of the population residing outside major cities and with limited medical access, telenephrology has a huge potential to provide quality nephrology care to the remotest parts of the country.

The Consultation and Relational Empathy (CARE) Measure, a validated questionnaire designed to assess patients' perceptions of their physician's communication skills and empathy, has been used to assess empathy in medical specialties but has seldom been applied to surgery. We assessed empathy and communication skills among a group of surgeons within a single academic institution.All surgeons within our department of surgery were invited to participate. Patients seen in clinics of participating surgeons were recruited prospectively from July 2018 to February 2019. At the end of each clinical encounter, they were asked to complete a CARE survey. Surveys were analyzed according to previously validated inclusion and exclusion criteria. We calculated mean scores for each surgeon and surgical division. About 6 months after study completion, surgeons were provided with their individual score and de-identified division scores, and were asked to complete a follow-up survey assessing their attitudes toward the CARE Measure.Of the 82 surgeons invited, 51 (62%) agreed to participate; 7 had fewer than 25 completed surveys and were excluded from analysis. A total of 1801 surveys for 44 surgeons (33 male and 11 female) were included in the final analysis. The average CARE score across the department was 46.9 (95% confidence interval [CI] 46.6-47.1). Female surgeons received significantly higher scores than male surgeons (mean 47.6 [95% CI 47.1-48.0] v. 46.7 [95% CI 46.4-48.0]). Of the 35 surgeons who responded to the follow-up survey, 31 (89%) felt that the questions in the CARE Measure applied to their practice, and half of these reported that they intended to make changes in response to the feedback.We found high communication and empathy scores among surgeons in the outpatient setting, with enough variability to encourage continued improvement. The CARE Measure appears to have face validity among surgeons, and the vast majority found it relevant to their practice. Further study is needed to formally assess the relevance, performance, reliability and construct validity of this measure.

The COVID-19 pandemic was a catalyst for the introduction of additional telehealth funding (telehealth item numbers) for general practitioner (GP) consultations through the Medicare Benefits Schedule (MBS) in Australia. This study evaluated the impact of telehealth funding on costs to the MBS for GP consultations from January 2017 to December 2021. An interrupted time series analysis assessed MBS costs (initial and monthly growth) for GP consultations (in-person, videoconference, telephone) before and after additional telehealth item numbers were introduced. From January 2017 to February 2020, total MBS costs for GP consultations were, on average, $545 million per month compared to $592 million per month from March 2020 to December 2021. There was an initial cost increase of approximately $39 million in the first month after additional telehealth funding was introduced ( p = 0.0001). Afterwards, there was no significant change in monthly costs ( p = 0.539). The introduction of additional MBS telehealth funding increased overall MBS costs for GP consultations. This increased cost for GP telehealth services could save costs to society if it translates into improved continuity of care, decreased hospitalisations, reduced productivity losses and improved patient outcomes. Future policy reform should incorporate a cost–benefit analysis to determine if increased MBS costs for GP consultations are a good investment.

In Australia, the COVID-19 pandemic has resulted in the exponential growth in the delivery of telehealth services. Medicare data indicates that the majority of telehealth consultations have used the telephone, despite the known benefits of using video. The aim of this study was to understand the perceived quality and effectiveness of in-person, telephone and videoconsultations for cancer care. Data was collected via online surveys with consumers ( n = 1162) and health professionals ( n = 59), followed by semi-structured interviews with telehealth experienced health professionals ( n = 22) and consumers ( n = 18). Data were analysed using descriptive statistics and significance was tested using the chi-square test. A framework analysis and thematic analysis were used for qualitative data. Results indicate telehealth is suitable for use across the cancer care pathway. However, consumers and health professionals perceived videoconsultations facilitated visual communication and improved patients’ quality of care. The telephone was appropriate for short transactional consultations such as repeat prescriptions. Consumers were rarely given the choice of consultation modality. The choice of modality depended on a range of factors such as the type of consultation and stage of cancer care. Hybrid models of care utilising in-person, video and telephone should be developed and requires further guidance to promote the adoption of telehealth in cancer care.

Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals.Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred.Veterans engaged through street outreach reported substantially more days of unsheltered homelessness in the past month (mean (M) = 11.18 days, s.d.=13.8) than the clinic-referred group (M = 6.75 days, s.d.=11.1), and were more likely to have spent the past 30 days unsheltered (RR = 2.23). There were notably few other differences between the groups.Despite epidemiologic evidence in the literature showing higher medical, psychiatric, and social and financial vulnerabilities among unsheltered homeless individuals, our street outreach group was not found to be any worse off on such variables than the clinic-referred or self-referred groups, other than increased time unsheltered. Outreach workers seem to engage more unsheltered individuals, but do not necessarily engage those with such severe vulnerabilities. Dedicated outreach program funding, training, and support are needed to support street outreach to those with the most severe problems.

Measurement of retinal thickness by optical coherence tomography (OCT) shows higher diagnostic accuracy for diabetic macular edema (DME) than fundus photography alone. The expanding gap between the rising number of type 2 diabetes (T2D) individuals and the availability of OCT devices demands a targeted selection of individuals at higher risk of DME who would benefit the most from early referral. We sought to appraise if proteinuria should be considered in a targeted referral of T2D individuals to OCT examination.This study was a cross-sectional analysis of 576 consecutive patients enrolled in the Brazilian Diabetes Study between June/2016 and December/2021 who underwent OCT exam and urinalysis to assess ME and proteinuria status, respectively. Differences in the prevalence of DME between proteinuria groups and across a range of diabetic retinopathy (DR) stages were evaluated.Among 1134 eyes included in this analysis, the prevalence of proteinuria was 22% and 18.2% of eyes had DME. Proteinuria was related to an increased prevalence of DME (13.2% vs 38.7% for control vs proteinuria, respectively;In T2D individuals, early referral to OCT examination should be pursued for all individuals with concurrent proteinuria.ClinicalTrials.gov Identifier: NCT04949152.

Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.

Objectives We assessed the inter-method bias of total (tPSA) and free (fPSA) prostate-specific antigen (PSA) immunoassays to establish if tPSA-based risk thresholds for advanced prostate cancer (PCa), obtained from one method (Roche) can be converted into the corresponding concentrations assayed by other methods. Then we evaluated the impact of the bias of tPSA and fPSA on the estimation of the %f/tPSA ratio and performed a re-calibration of the proposed thresholds for the %f/tPSA ratio according to the assay used. Methods tPSA and fPSA were measured in 135 and 137 serum samples, respectively by Abbott Alinity i, Beckman Access Dxl, Roche Cobas e801, and Siemens Atellica IM analytical platforms. Scatterplots, Bland-Altman diagrams, Passing-Bablok (PB) were used to inspect and estimate the systematic and proportional bias between the methods. The linear equations with confidence intervals of the parameter estimates were used to transform the tPSA risk thresholds for advanced PCa into the corresponding concentrations measurable by the other analytical methods. To construct a correction coefficient for converting the %f/tPSA ratio from one method to the other, PB and non-parametric boostrapping were used. Results The inter-method bias is not constant but strictly linear allowing the conversion of PSA results obtained from Roche into the other assays, which underestimate tPSA vs. Roche. Siemens and Abbott vs. Roche and Beckman assays, being characterized by a positive and a negative proportional bias for tPSA and fPSA measurements, tend to overestimate the %f/tPSA ratio. Conclusions There is a consistent risk to miss advanced PCa, if appropriate conversion factors are not applied.

Linking clinical services to community-based resources is a promising strategy for assisting patients with chronic disease prevention and management. However, there remains a gap in understanding how to effectively develop and implement community–clinical linkages (CCLs), especially in communities of color. The Healthy Here initiative used Stage Theory of organizational change to implement a centralized wellness referral system, linking primary care clinics to community organizations in majority Hispanic/Latinx and Native American communities. Data were collected using a standardized referral form. Facilitators and challenges were identified through semi-structured discussions with partner organizations. Between 2016 and 2021, 43 clinics and 497 health care providers made 7,465 referrals, the majority of which were from the focus populations. The average proportion of patients referred by clinic champions decreased significantly over time, reflecting diffusion of the intervention within clinics. Facilitators to system success included building on existing networked partnerships, utilizing a centralized referral center, leveraging funding, sharing data, addressing challenges collectively, incorporating multilevel leadership, and co-developing and testing a standardized referral form and process with a single clinic and provider before scaling up. Challenges included funding restrictions, decreasing referrals within clinics over time, changing availability of resources and programs, and the COVID-19 pandemic. This innovative initiative demonstrates that CCLs can be developed and implemented to successfully reach Hispanic/Latinx and Native American communities and provides strategies for overcoming challenges.

Consultation is an important implementation strategy to improve treatment fidelity and clinical outcomes, yet research has not identified the aspects of consultation that differentially affects clinician skill development and client symptom change. Thus, the present study investigated the effect of the consultant, consultation activities, and consultants' (n = 6) perceptions of consultees (n = 60) on post-traumatic stress disorder (PTSD) treatment fidelity and client outcomes. In addition, we assessed the accuracy of consultants' evaluations of clinicians using the Perceived Enthusiasm, Skill, and Participation scale (P-ESP). Results indicated that there was a significant effect of consultant on adherence to, but not competence in, delivering Cognitive Processing Therapy (CPT). The effect of the consultant on PTSD symptom change was not significant. Consultants significantly differed in their discussion of CPT strategies and their application to individual cases, but did not differ on reviewing and providing feedback on fidelity. Consultant perceptions as assessed by the P-ESP were not associated with clinicians' current levels of adherence or competence, suggesting that consultants may not accurately assess clinician skill during consultation. Client PTSD symptom change neither predicted, nor was predicted by, consultants' perceptions of their consultees' skill. This article outlines potential reasons for consultant effects and possible biases at play that may reduce the accuracy of consultant perceptions and presents suggestions on alternative strategies to assess clinician skill during consultation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Crisis stabilization units (CSUs), which offer a range of short-term psychiatric and psychological services, are one of several treatment programs that may create "alternative to arrest" options for law enforcement. Here, we examined the characteristics of the population who was referred to a newly established CSU in its first year of operation and examined the impact of the CSU on regional jail bookings. Administrative medical records and regional jail booking data were merged to form our study sample. Adults who had at least one jail booking and/or one CSU admission during our study period were included. We found that from September 1, 2018 to August 30, 2019, 458 people were admitted into the CSU. Approximately one-third (33.8%) had a jail booking during the study period. In the 3 months following CSU admission, 4.1% had an increase in jail bookings, 11.1% had a decrease, and 66.2% had no change. CSU patients self-reported high depressive and posttraumatic stress disorder symptoms, while also reporting low quality of life scores overall. We conclude that CSUs may be promising components of jail diversion efforts, providing critical services to populations experiencing significant mental health symptoms and who are at risk for incarceration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

To describe lactation outcomes among of a cohort of mother-infant dyads in which the women had an individualized prenatal nutrition consultation intervention.Descriptive cohort study.A free-standing children's hospital with a center for fetal diagnosis and treatment and a specialized maternity unit.A total of 160 women who had prenatal nutrition consultations in 2014 to 2017 and gave birth to infants with known congenital anomalies and required intensive care after birth.We surveyed women regarding their lactation outcomes after the Breastfeeding Report Card metrics of the Centers for Disease Control and Prevention and obtained permission to abstract demographic and clinical information from the setting's electronic health record. We analyzed data with standard descriptive statistics.Among the cohort, 86.9% (n = 139) of participants intended to provide human milk or combination feeding in the prenatal period. A total of 128 (92.1%) infants were first exposed to human milk enterally. At the time of discharge, 92.1% (n = 128) of the infants received human milk. The breastfeeding outcomes of the cohort significantly surpassed national data: initiation (98.1% vs. 84.1% national), breastfeeding at 3 months (89.4%), exclusive breastfeeding at 3 months (60% vs. 46.9% national), breastfeeding at 6 months (76.9% vs. 58.3% national), exclusive breastfeeding at 6 months (45% vs. 25.6% national), breastfeeding at 12 months (50.6% vs. 35.3% national), and breastfeeding beyond 12 months (34.4%).Lactation outcomes among women who had prenatal nutrition consultations far surpassed national data, and this intervention has implications for family-centered prenatal care, informed decision making, and improved breastfeeding outcomes in the hospital setting and postdischarge.

PURPOSE:The Cannabis Consultation Service (CCS) is an innovative pharmacist-led resource at the Sunnybrook Odette Cancer Centre. Its mandate is to provide education and guide patients through access and appropriate use of high-quality plant-derived cannabinoids (PDCs). Our objective was to describe the CCS, explain its processes, and characterize patient disposition with respect to use of PDCs.METHODS:We retrospectively reviewed the charts of patients referred to the CCS from July 13, 2020, to March 05, 2021. We used descriptive statistics to report on the patient population and service metrics.RESULTS:During the 34-week period, 96 patients accessed the CCS (median age, 61 years). The top reasons for CCS consultation were management of cancer pain, insomnia, and general interest. Medical cannabis was supported as an option in 44/96 patients. Reasons for not supporting PDC use included lack of indication, potential drug interaction/contraindication, or requiring treatment with first-line therapy. Of the 40 patients requiring a medical document, 22 initiated therapy. The most common product used was a 2:50 THC:CBD (Tetrahydrocannabinol:Cannabidiol) cannabis oil. At the date of last contact, few patients remained on therapy because of lack of benefit, patient choice, and/or hesitancy.CONCLUSION:Despite patients with cancer having interest in seeking PDCs for symptom management, only a few initiated and continued therapy. Pharmacists have an opportunity to advise patients and the oncology team on the risks and benefits of PDCs. These results can be used to support the development of medical cannabis programs by oncology centers and focus future research priorities.

There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.

Popliteal Artery Entrapment Syndrome (PAES) is a rare clinical entity without a standardized algorithm for diagnosis and treatment. The objective of this study was to evaluate the clinical outcomes of a unique diagnostic and management algorithm for patients with PAES managed at a quaternary referral center.We retrospectively reviewed patients diagnosed with PAES at a single institution between 2013 and 2021. Demographics, physical exam findings, noninvasive imaging results, and angiographic images were assessed to validate a diagnostic and management algorithm (Figure 1). Surgical findings, operative technique, post-operative complications, and symptomatic improvement were assessed to validate this clinical algorithm.There were 35 extremities in 23 patients treated for PAES (Table I). The mean age was 28, and 82.6% of patients were female. Physical exam revealed a decrement in pedal pulse with provocative maneuvers in 90% of treated limbs. Noninvasive studies to include treadmill exercise testing revealed a mean Ankle-brachial indices (ABI) drop of 0.28 and positional duplex demonstrated that the mean peak systolic velocity (PSV) in the popliteal artery was 78 cm/sec at rest which increased to 175 cm/sec with provocation. Diagnostic arteriography was performed in all patients and revealed awell-developed geniculate and sural collaterals in 100% of the treated limbs and complete effacement of the popliteal artery with active provocative maneuvers in all treated limbs (Figure 2). Surgical exposure was performed via a posterior approach and intraoperative completion duplex was performed in all cases. Type III PAES was discovered in 89% of cases. Arterial reconstruction was required in 2 patients who presented with an occluded popliteal artery. All but one patient was discharged on post-operative day one. Wound complications occurred in 4 limbs (3 patients) and included seroma and hypertrophic scarring. All patients experienced symptomatic relief with a median follow-up of 4 months.We reported 100% technical and clinical success in patients with PAES diagnosed and managed using our clinical algorithm. Cross-sectional imaging is not necessary for the diagnosis. Dynamic angiography confirms the diagnosis and intraoperative duplex is essential for successful clinical outcome by confirming complete release of the popliteal artery.

Children and adults with advanced cardiac or respiratory disease may benefit from specialized palliative care (SPC), but there has been little SPC research in this area.To explore pediatric cardiologists' and respirologists' (pediatric clinicians) beliefs about and referral practices to SPC and compare these results to adult cardiologists and respirologists (adult clinicians).Pediatric and adult clinicians were sent a survey exploring SPC referral practices and beliefs. Responses were summarized with descriptive statistics. Pediatric and adult clinicians' responses were compared using Pearson's chi-square test.The response rate was 56% (989/1759); 9% (87/989) were pediatric clinicians. Pediatric clinicians were more likely than adult clinicians to be female, work in an academic center, and experience fewer patient deaths (P0.001). Pediatric clinicians reported better access to SPC clinical nurse specialists, spiritual care specialists and bereavement counselors (P0.001), while adult clinicians reported better access to palliative care units (P0.001). Pediatric clinicians referred to SPC earlier, while adult clinicians tended to refer after disease directed therapies were stopped (P0.001). More than half of all clinicians felt patients had negative perceptions of the phrase "palliative care". Although most clinicians were satisfied with SPC quality (73-82%), fewer adult clinicians were satisfied with SPC availability (74 vs. 47%; P0.001). Fewer pediatric clinicians felt that SPC prioritized oncology patients (13 vs. 53%; P0.001).There are important differences between pediatric and adult clinicians' beliefs about and referral practices to SPC. This may reflect unique features of pediatric diseases, provider characteristics, care philosophies, or service availability.

OBJECTIVES The extent that universal social determinants of health (SDH) screening in clinical encounters, as recommended by the American Academy of Pediatrics, has been implemented in inpatient pediatric settings is unknown. We aimed to determine the national prevalence and predictors of standardized SDH screening in US level 2 to 4 neonatal care units (NICUs), describe characteristics of SDH screening programs, and ascertain beliefs of clinical leaders about this practice in the NICU setting. METHODS We randomly selected 100 hospitals with level 2 to 4 NICUs among each of 5 US regions (n = 500) and surveyed clinical leaders from January to November 2021 regarding standardized SDH screening. Responses were weighted for number of level 2 to 4 NICUs in each region and nonresponse. RESULTS Overall response rate was 34% (28%–40% by region). Twenty-three percent of US level 2 to 4 NICUs reported standardized SDH screening. We found no associations of hospital characteristics, such as region, size, or safety-net status, with implementation of this practice. Existing programs conducted systematic screening early in the hospitalization (84%), primarily led by social workers (92%). We identified practice variation regarding the type of screening tool, but there was substantial overlap among domains incorporated in the screening. Reported barriers to implementation included perceived lack of resources, inadequate referrals, and lack of an inpatient screening tool. CONCLUSIONS The prolonged neonatal hospitalization provides opportunities to systematically address SDH. Yet, only 23% of US level 2 to 4 NICUs have implemented this practice. To scale-up implementation, quality improvement may support adaptation of screening and referral processes to the NICU context.

Research on abortion referral practices has focused on referral to first-trimester abortion care. Research has not examined whether and how these recommendations apply to referrals for abortion later in pregnancy.We conducted a secondary analysis of semi-structured interviews with thirty third-trimester abortion patients of their experiences of referral from prenatal and/or pre-third-trimester abortion care. We used thematic coding to identify referral-related actions participants desired or wished providers would avoid.Participants reported needs in referral for information that third-trimester abortion was a possibility and about third-trimester providers and funding resources. Several also reported a need for emotional support from the prenatal or abortion care provider who denied them abortion care.Many factors important for first-trimester abortion referral are important in third-trimester abortion referral, but the specifics of third-trimester care (namely the paucity of clinics, need for travel, and possibility of strong emotional attachment to the pregnancy) require additional practice actions.Providers can support their patients in need of third-trimester abortion care by proactively providing: information that third-trimester abortion is available; information on third-trimester providers and funding support (e.g., an abortion referral hotline); and clear, non-judgmental emotional support.

Young adults with intellectual/developmental disabilities (YAIDD) are a vulnerable population during HCT due to their complex care coordination and adaptive needs, yet factors associated with transition preparedness are not well defined. We aimed to determine factors associated with health care transition (HCT) preparation satisfaction for YAIDD establishing care with an adult medical home.408 YAIDD or their families completed the HCT Feedback Survey 2.0 upon establishing adult care. Logistic regression models were used to determine associations between a composite of six HCT Feedback Survey questions that most correlated with the 2019 National Survey of Children's Health transition questions.YADD who had HCT preparation visits with a designated HCT clinic were 9 times more likely to have met all six composite HCT criteria after controlling for the number of technologies required and race/ethnicity (adj OR 9.04, 95% CI: 4.35, 18.76) compared to those referred from the community. Compared to patients who were referred from the community, the odds of feeling very prepared versus somewhat or not prepared were 3.7 times higher (adj OR 3.73, 95% CI: 1.90, 7.32) among patients referred from a designated HCT program.YAIDD who participated in a structured HCT program prior to transfer to adult care experienced higher transition preparation satisfaction.A structured HCT clinic model to prepare adolescents with DD for transition to adult care may improve HCT preparation satisfaction for this population.

Sexual violence (SV) has significant impacts on physical, social and psychological wellbeing, with associated mental illness and suicide. Despite no specific guidelines regarding mental health and SV, recommendations suggest all patients should have the opportunity to discuss their mental health and be offered referrals for support. A service evaluation was performed at a large Sexual and Reproductive Health Service (SRHS) with n = 179 patient records reviewed between 30/07/2021 to 01/10/21, who had disclosed SV including n = 83 referred from Sexual Assault Referral Centres (SARC). Patient exclusions included duplicates and non-attendances. Data on patient demographics, mental health assessment and referral services were analysed. Referral services included Independent Sexual Violence Advisors (ISVAs), a specialist third sector organisation Rape and Sexual Violence Project (RSVP), and an inhouse specialist SV clinic, Abuse Survivors Clinic (ASC). Demographic analysis demonstrated that 43% of cases were aged over 25 years, 47% were 18–25 and 10% under 18. Females comprised 85% of cases. Mental health history was documented in 91% of SARC referrals, compared to 77% of patients who directly attended SRHS. Current mental health was assessed in 83% of SARC referral patients, compared to 75% of direct SRHS patients. RSVP was offered to 81% of patients, more than any other service. ISVA was offered to 40% of patients, and ASC was offered to 3% of patients. In total, 11% of patients were offered no service referrals. Findings suggest improvements should be made to ensure all patients have discussions around their mental health and are offered support services following SV disclosure. Further research is required to determine whether these changes improve patient outcomes.

Introduction. In late February 2020, after we had informed about the presence of some cases of COVID-19 in Iran and its rapid spread throughout the country, we decided to make the necessary arrangements for patients with critical conditions in Pediatric Intensive Care Unit (PICU) at Children's Medical Center. There are a little data on critically ill children with COVID-19 infection with ICU requirements. The aim of this study was to describe clinical characteristics, laboratory parameters, treatment, and outcomes of the pediatrics population infected by SARS-CoV-2 admitted to PICU. Materials and Methods. This study was performed between February 2020 and May 2020 in the COVID PICU of the Children’s Medical Center Hospital in Tehran, Iran. Patients were evaluated in terms of demographic categories, primary symptoms and signs at presentation, underlying disease, SARS-CoV-2 RT-PCR test result, laboratory findings at PICU admission, chest X-ray (CXR) and lung CT findings, and treatment. Moreover, the need to noninvasive ventilation (NIV) or mechanical ventilation, the length of hospital stay in the PICU, and outcomes were assessed. Results. In total, 99 patients were admitted to COVID PICU, 42.4% (42 patients) were males, and 66 patients had positive SARS-CoV-2 real-time reverse transcriptase-polymerase chain reaction (RT-PCR). There was no statistically significant difference in the frequency of clinical signs and symptoms (except for fever) among patients with positive SARS-CoV-2 RT-PCR and negative ones. Among all admitted patients, the presence of underlying diseases was noticed in 81 (82%) patients. Of 99 patients, 34 patients were treated with NIV during their admission. Furthermore, 35 patients were intubated and treated with mechanical ventilation. Unfortunately, 11 out of 35 mechanically ventilated patients (31%) passed away. Conclusion. No laboratory and radiological findings in children infected with COVID-19 were diagnostic in cases with COVID-19 admitted to PICU. There are higher risks of severe COVID-19, PICU admission, and mortality in children with comorbidities.

Infant and Early Childhood Mental Health Consultation (IECMHC) aims to improve early childhood professionals' abilities to promote children's mental health through relationship building and collaboration. Using a longitudinal, matched-comparison group design, a 3-year pilot study of a cross-system, embedded model of IECMHC assessed teachers and home visitors in intervention and comparison programs in reflective capacity, burnout, and perceptions of children's behavior. A sample of 136 staff (n = 72 intervention group; n = 64 comparison group; 21% Black; 51% White; 28% Latina/Hispanic) participated in surveys over a 21-month implementation period. A subsample of staff (n = 26) participated in interviews that included a narrative measure of reflective capacity; and a smaller subsample of teachers only (n = 21) completed assessments of children. Staff in the intervention group significantly increased reflective capacity after 21 months. For the staff interview subsample, receiving the intervention predicted lower levels of burnout at 12-15 months post-baseline. Among teachers completing child assessments, those with higher reflective capacity rated children's behaviors more positively than teachers with lower reflective capacity. We conclude that this IECMHC model successfully improved reflective capacity in staff. Future research should investigate reflective capacity as a potential mechanism of change for IECMHC.La Consulta de Salud Mental de la Infancia y la Temprana Niñez (IECMHC) se propone mejorar las habilidades de los profesionales de la temprana niñez para promover la salud mental de los niños por medio de establecer relaciones y de la colaboración. Usando un diseño longitudinal, de un grupo de comparación emparejado, un estudio experimental de tres años con un modelo incorporado de IECMHC a lo largo del sistema, evaluó a instructores y visitadores a casa en programas de intervención y comparación en cuanto a la capacidad de reflexión, el agotamiento, así como las percepciones del comportamiento de los niños. Un grupo muestra de 136 miembros del personal (n = 72 en el grupo de intervención; n = 64 en el grupo de comparación; 21% negros; 51% blancos; 28% hispano/latino) participó en entrevistas que incluían una medida narrativa de la capacidad de reflexión; y un más pequeño subgrupo muestra de instructores solamente (n = 21) completaron evaluaciones de los niños. Los miembros del personal en el grupo de intervención significativamente aumentaron la capacidad de reflexión después de 21 meses. Para la entrevista del personal en el subgrupo muestra, recibir la intervención predijo más bajos niveles de agotamiento a los 12 a 15 meses después del punto de partida. De los instructores que completaron las evaluaciones del niño, aquellos con más alta capacidad de reflexión evaluaron el comportamiento de los niños más positivamente que los instructores con una más baja capacidad de reflexión. Concluimos con que este modelo de IECMHC mejoré con éxito la capacidad de reflexión del personal. La investigación futura debe investigar la capacidad reflexión como un potencial mecanismo de cambio para IECMHC.La consultation de Santé Mentale du Nourrisson et de la Petite Enfance (abrégé IECMHC en anglais) a pour but d'améliorer les compétences des professionnels de la petite enfance à promouvoir la santé mentale des enfants au travers de l’établissement de relations et de la collaboration. En utilisant une conception de groupe témoin apparié, longitudinale, une étude pilote de trois années d'un modèle inter-système et intégré de IECMHC a évalué des enseignants et des visiteurs à domicile dans des programmes d'intervention et de comparaison pour ce qui concerne la capacité de réflexion, le burnout et les perception du comportement des enfants. Un échantillon de 136 employés (n = 72 groupe d'intervention; n = 64 groupe de comparaison; 21% Noirs; 51% Blancs; 28% Hispaniques / Latinas) ont participé à des enquêtes sur une période de mise en place de 21 mois. Un sous-échantillon d'employés (n = 26) a participé à des entretiens qui ont inclus une mesure narrative de capacité de réflexion; et un plus petit sous-échantillon d'enseignants uniquement (n = 21) a rempli des évaluations des enfants. Les employés dans le groupe d'intervention ont fortement augmenté leur capacité de réflexion après 21 mois. Pour le sous-échantillon d'employés, le fait d'avoir reçu l'intervention a prédit des niveaux plus bas de burnout à 12-15 mois après référence. Des enseignants ayant rempli les évaluations des enfants, ceux avec la capacité de réflexion la plus élevées ont évalué les comportements des enfants de manière plus positive que les enseignants avec une capacité de réflexion moins élevée. Nous concluons que ce modèle IECMHC a amélioré avec succès la capacité de réflexion chez les employés. Des recherches futures devraient se pencher sur la capacité de réflexion comme mécanisme potentiel de changement pour l'IECMHC.Aufbau von Reflexionsfähigkeit und Verbesserung des Wohlbefindens bei Fachkräften für Früherziehung durch ein eingebettetes systemübergreifendes Beratungsmodell zur psychischen Gesundheit von Säuglingen und Kleinkindern „Infant and Early Childhood Mental Health Consultation“ (IECMHC) zielt darauf ab, durch Beziehungsaufbau und Zusammenarbeit im Kontext von Früherziehung Fähigkeiten zur Förderung der psychischen Gesundheit von Kindern zu verbessern. Unter Verwendung eines Längsschnittdesigns mit einander angepassten Vergleichsgruppen wurden in einer dreijährigen Pilotstudie eines systemübergreifenden, eingebetteten IECMHC-Modells Früherzieher:innen und Hausbesuchende, aufgeteilt in Interventions- und Vergleichsprogramme, bezüglich ihrer Reflexionsfähigkeit, Burnout und ihrer Wahrnehmung von kindlichem Verhalten untersucht. Eine Stichprobe von 136 Mitarbeitenden (n = 72 Interventionsgruppe; n = 64 Vergleichsgruppe; 21 % afroamerikanisch; 51 % weiße; 28 % Latinas/Hispanics) nahm über einen 21-monatigen Implementierungszeitraum an Umfragen teil. Eine Teilstichprobe von Mitarbeitenden (n = 26) nahm an Interviews teil, die eine narrative Messung der Reflexionsfähigkeit beinhalteten. Nur eine kleinere Teilstichprobe von Erzieher:innen (n = 21) nahm eine Beurteilung der Kinder vor. Bei den Mitarbeitenden in der Interventionsgruppe erhöhte sich die Reflexionsfähigkeit nach 21 Monaten signifikant. In der Teilstichprobe der Mitarbeitenden, die interviewt wurden, prognostizierte der Erhalt der Intervention 12-15 Monate nach der Baseline-Messung ein geringeres Burnout-Niveau. Von den Erzieher:innen, die die Beurteilung der Kinder durchführten, bewerteten diejenigen mit höherer Reflexionsfähigkeit das Verhalten der Kinder positiver als Erieher:innen mit geringerer Reflexionsfähigkeit. Wir schließen daraus, dass dieses IECMHC-Modell die Reflexionsfähigkeit der Mitarbeitenden erfolgreich verbessert hat. Zukünftige Forschung sollte die Reflexionsfähigkeit als möglichen Veränderungsmechanismus bei IECMHC untersuchen.乳幼児精神保健コンサルテーションの横断的システム組込モデルによる、 乳幼児専門家の内省的能力の構築と幸福度の向上 乳幼児精神保健コンサルテーション (IECMHC) の目的は、乳幼児の専門家の関係性の構築と連携により子どもの精神的健康を促進する能力の向上である。縦断的なマッチドコンパリゾンデザインのもと行われた、IECMHCの横断的システム組込モデルの3年間のパイロットスタディでは、介入プログラムと対象プログラムそれぞれの教師とホームビジターについて、内省的能力、バーンアウト、子どもの行動に関する認知を評価した。136人のスタッフ (介入群72人、比較群64人、黒人21％、白人51％、ラテン系・ヒスパニック28％) が、21ヶ月間の実施期間中に調査に参加した。スタッフの下位サンプル (n = 26) は、内省力の物語的尺度を含む面接に参加し、より少ない下位サンプルの教師のみ (n = 21) が子どもの評価を行った。介入群のスタッフは、21ヵ月後に内省力を有意に増大させた。インタビューを受けた下位サンプル群では、介入を受けたことにより、ベースライン後12～15か月におけるバーンアウトのレベルが下がることが予測された。子どもの評価を行う教師のうち、内省力の高い教師は、低い教師に比べ子どもの行動をより肯定的に評価した。我々は、このIECMHCモデルがスタッフの内省力の向上に成功したと結論づけた。今後、IECMHC の潜在的な変化のメカニズムとしての内省力についてさらなる研究をする必要がある。.“婴幼儿心理健康咨询” (IECMHC) 旨在提高幼儿专业人员通过建立关系和合作促进儿童心理健康的能力。采用纵向匹配对照组设计, 对一个IECMHC跨系统的、嵌入式模型进行了为期三年的试点研究, 评估了教师和家访者在干预及对照项目中的反思能力、倦怠和对儿童行为的看法。在21个月的项目实施期内, 抽样调查了136名工作人员 (干预组 n = 72;对照组 n = 64;21%黑人;51%白人;28%拉丁裔或西班牙裔) 。工作人员子样本 (n = 26) 参加了访谈, 其中包括对反思能力的叙述性测量;只有更小的教师子样本 (n = 21) 完成了对儿童的评估。干预组的工作人员在21个月后显著提高了反思能力。对于工作人员访谈子样本, 接受干预12-15月以后其倦怠水平更低。在完成儿童评估的教师中, 反思能力较高的教师比反思能力较低的教师对儿童行为的评价更为积极。我们的结论是, 该IECMHC模型成功地提高了工作人员的反思能力。未来的研究应探讨反思能力作为IECMHC变化的潜在机制。.بناء القدرة التأملية وتحسين رفاهية متخصصي الطفولة المبكرة من خلال نموذج شامل لنظام استشارات الصحة النفسية للرضع في مرحلة الطفولة المبكرة تهدف استشارات الصحة النفسية للرضع والطفولة المبكرة (IECMHC) إلى تحسين قدرات اختصاصيي الطفولة المبكرة على تعزيز الصحة النفسية للأطفال من خلال بناء العلاقات والتعاون. باستخدام تصميم مجموعة المقارنة الطولية ، ودراسة تجريبية مدتها ثلاث سنوات لنظام متقاطع ، ونموذج مضمن لـ IECMHC تم تقييم المعلمين وزوار المنزل في برامج التدخل والمقارنة من حيث القدرة التأملية ، والإرهاق ، وتصورات سلوك الأطفال. شاركت عينة من 136 موظفًا (ن = 72 مجموعة تدخل ؛ ن = 64 مجموعة مقارنة ؛ 21٪ سود ؛ 51٪ بيض ؛ 28٪ هسبانيك/لاتين) في استطلاعات على مدى فترة تنفيذ مدتها 21 شهرًا. شاركت عينة فرعية من الموظفين (ن = 26) في المقابلات التي تضمنت مقياسًا سرديًا للقدرة التأملية ؛ وعينة فرعية أصغر من المعلمين فقط (ن = 21) استكملت تقييمات للأطفال. زاد الموظفون في مجموعة التدخل بشكل ملحوظ من القدرة على التأمل بعد 21 شهرًا. بالنسبة للعينة الفرعية لمقابلة الموظفين ، فإن تلقي التدخل تنبأ بمستويات أقل من الإرهاق في 12-15 شهرًا بعد خط الأساس. من بين المعلمين الذين أكملوا تقييمات الأطفال ، قام أولئك الذين يتمتعون بقدرة أعلى على التأمل بتصنيف سلوكيات الأطفال بشكل أكثر إيجابية من المعلمين الذين لديهم قدرة تأملية أقل. نستنتج أن هذا النموذج من IECMHC نجح في تحسين القدرة التأملية في الموظفين. يجب أن يتناول البحث المستقبلي القدرة التأملية كآلية محتملة للتغيير في استشارات الصحة النفسية للرضع والطفولة المبكرة.

Invasive group B Streptococcus (GBS) infections are increasing among adults with underlying health conditions; however, clinical manifestations and serotype distribution remain unclear. This study investigated the molecular characteristics and antimicrobial resistance of invasive GBS in Korean adults. GBS isolates from patients with invasive diseases during 2006-2015 were investigated for capsular serotype, multilocus sequence type (ST), antimicrobial susceptibility, and resistance genes. Among the 74 isolates analyzed, the most common serotype was Ib (31.1%), followed by III (21.6%), V (20.3%), Ia (12.2%), and VI (12.2%). Thirteen STs were detected, with ST1, ST10, ST19, and ST23 as the most prevalent. The dominant capsular serotype exhibited by ST1 was V, and those expressed by ST10, ST19, and ST23 were Ib, III, and Ia, respectively. Erythromycin and levofloxacin resistance were observed in 33.8% and 31.1% of the isolates, respectively. ST10-Ib (n = 11/11, 100%) and ST654-Ib (n = 3/3, 100%) were dominant levofloxacin-resistant strains. Serotypes Ib, III, and V were most common among adults, which is inconsistent with recent reports in Korea where III, V, and Ia were predominant in infants. The difference in the serotype distribution between adults and children may be associated with the selective pressure imparted by antibiotics.