International evidence on lived experiences of trauma during homelessness and effects on mental health including substance use: a co-produced qualitative systematic review.

BACKGROUND: Trauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use. METHODS: In this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist. FINDINGS: We included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances. INTERPRETATION: Further evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation. FUNDING: National Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19.

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

The Development of a Long Peripheral Catheter Program at a Large Pediatric Academic Center: A Pilot Study.

OBJECTIVES: The purpose of this study was to evaluate the feasibility of a new long peripheral catheter (LPC) program at a large academic center in an effort to reduce the use of peripherally inserted central catheters (PICCs) and their related complications. METHODS: The pilot participants were hospitalized children, age >2 years, with a need for noncentral intravenous access for 2 to 29 days, or laboratory blood draw >5 times per day. Patients expected to discharge with intravenous access were excluded. Included in the pilot program development were a literature review, 1-year baseline data analysis, and program design and implementation. A multidisciplinary committee developed and implemented the program from December 2018 to September 2019. LPCs were placed from August to September 2019. RESULTS: Regarding the baseline data, between July 2018 and June 2019, 584 PICCs were placed in 461 patients. Of these, 139 PICCs (24%) did not meet requirements necessitating central access and, potentially, could have been avoided if an LPC alternative were available at the time. For the LPC pilot program, 20 LPCs were placed in 19 patients. The median age was 11 (interquartile range of 7-15). The insertion success rate was 83%. There were no serious complications, such as venous thrombosis or catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% (n = 2), and the rate of dislodgement was 25% (n = 5). The catheter failure rate was 74 per 1000 catheter-days. The mean line duration was 6 days. CONCLUSIONS: There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.

Near-infrared Spectroscopy in Transport With a Patient in Multi-factorial Shock.

A 14-year-old male with a history of repaired truncus arteriosus presented to an outside hospital emergency room in respiratory distress. The triage report to the transport referral center included the following vital signs: temperature of 36.6°C, respiratory rate (RR) of 26 breaths/min, heart rate (HR) of 144 beats/min, and blood pressure (BP) of 113/52 mm Hg with peripheral capillary oxygen saturation (SpO2) of 95% on 4 L via an OxyMask (SouthMedic, Barrie, Ontario, Canada). Additional information indicated severe right ventricle to pulmonary artery conduit stenosis; anuria for 2 days; and cool, mottled extremities. The transport team was dispatched via helicopter. The vital signs upon arrival were as follows: temperature of 36.5°C, HR of 153 beats/min, RR of 48 breaths/min, BP of 81/52, mean arterial pressure of 62, and SpO2 of 96% on 8 L via an OxyMask. Physical assessment revealed the patient was alert and oriented, tachypneic, tachycardic, and displaying poor perfusion. An epinephrine drip was initiated while the patient was being prepared for transport. Near-infrared spectroscopy (NIRS) was initiated with cerebral NIRS of 71% and renal NIRS of 39%. The epinephrine drip was escalated, and norepinephrine was initiated and titrated up for continued poor perfusion and low renal NIRS. Vitals at the transfer of care at the receiving facility were HR of 142 beats/min, BP of 91/51 mm Hg, RR of 56 breaths/min, SpO2 of 99%, and cerebral NIRS of 75% and renal NIRS of 53%. The patient required mechanical circulatory support shortly after admission. NIRS monitoring was used to help measure perfusion and reassess interventions made during transport.

Efficacy of Amphotericin B Against Fusarium and Aspergillus in Corneal Storage Medium.

PURPOSE: The incidence of postkeratoplasty fungal infection is increasing in the United States, and our most commonly used corneal storage medium, Optisol-GS, contains antibiotics but no antifungal agents. We previously demonstrated the efficacy of amphotericin B additives in eliminating Candida albicans contaminants in Optisol-GS. The purpose of this study was to determine whether amphotericin B would also be efficacious against Fusarium solani and Aspergillus fumigatus. METHODS: Vials of Optisol-GS were supplemented with 0.255 µg/mL of amphotericin B. Half of the vials were inoculated with F. solani and half with A. fumigatus. Positive control vials were inoculated with the fungi but no amphotericin B. The vials were refrigerated, sampled, and plated at different time points. The plates were then incubated at 36°C for 48 hr after which fungal colony counts were performed. RESULTS: There was an average reduction in the growth of F. solani in the amphotericin B-supplemented vials of 44% on day 2, 79% on day 7, and 80% on day 14 when compared with the positive control vials. There was an average reduction in the growth of A. fumigatus in the amphotericin B-supplemented vials of 40% on day 2 and 14% on day 7 when compared with the positive control vials. Both amphotericin B-supplemented and control vials grew less than 2 colonies of A. fumigatus on day 14. CONCLUSIONS: This study suggests that amphotericin B additives in Optisol-GS reduce the growth of F. solani and A. fumigatus.

The Effect of Light Exposure on the Efficacy and Safety of Amphotericin B in Corneal Storage Media.

IMPORTANCE: The proportion of postkeratoplasty fungal infections is rising steadily. However, the most commonly used corneal storage medium in the United States, Optisol-GS, does not contain an antifungal additive. OBJECTIVES: To determine the lowest concentration of amphotericin B supplementation in Optisol-GS that will eliminate fungal contaminants effectively without resulting in toxic effects to the cornea and to determine what role light exposure plays in the efficacy and safety of amphotericin B supplementation. DESIGN, SETTING, AND MATERIALS: An in vitro laboratory efficacy study measured fungal colony growth in 10 vials of Optisol-GS supplemented with different concentrations of amphotericin B after inoculation with Candida albicans in light-exposed and light-protected conditions. Two vials each were supplemented with amphotericin B at concentrations of 0.06, 0.12, or 0.225 µg/mL; the remaining 2 vials received no C albicans inoculation and no antifungal supplementation (negative controls). After 24 hours, 1 vial from each pair was exposed to light for the remainder of the study. On days 2, 7, and 14, 1 mL of solution was removed from each vial and incubated at 36°C for 48 hours. In a separate safety study, 12 pairs of corneas were divided between amphotericin B supplementation and the control condition; 4 corneas each received the different amphotericin B concentrations. An additional 4 pairs of corneas were stored in the 0.225-µg/mL concentration, and 1 cornea from each pair was exposed to light for the duration of the study. Data were collected November 16, 2014, and analyzed from November 16 to 18, 2014, for the efficacy study; they were collected from April 14 to May 27, 2015, and analyzed from May 28 to 30, 2015, and on December 23, 2015, for the safety study. MAIN OUTCOMES AND MEASURES: Fungal colony growth was measured from the Optisol-GS vials. Corneal endothelial cell density, endothelial cell viability, and epithelial toxic effects were measured in stored corneas. RESULTS: In the efficacy study, Optisol-GS supplemented with concentrations of 0.06 and 0.12 µg/mL of amphotericin B eliminated all fungal contaminants by day 7 and reduced fungal growth on day 2 by a mean of 3.5 colony-forming units (95% CI, -6.19 to 13.20 colony-forming units; P = .34), a 77.8% decline compared with the postoperative controls. Optisol-GS supplemented with the 0.255-µg/mL concentration of amphotericin B eliminated all fungal contaminants by day 2. In the safety study, no evidence was found of toxic effects to the cornea in corneas stored in Optisol-GS supplemented with amphotericin B at any concentration compared with paired controls. No difference in the efficacy or safety of the light-exposed compared with light-protected amphotericin B-supplemented Optisol-GS was identified. CONCLUSIONS AND RELEVANCE: In this study, Optisol-GS supplemented with a 0.255-µg/mL concentration of amphotericin B effectively eliminated fungal contaminants within 48 hours and did not result in added toxic effects to the cornea. These results do not prove that amphotericin B should be added to Optisol-GS; larger-scale studies and cost-benefit analyses need to be completed. Given the increasing incidence of postkeratoplasty fungal infection, however, the addition of amphotericin B to Optisol-GS deserves further investigation.

Using group preceptorship to support novice nurses.

This article shares the experience of ward leaders in devising and facilitating a group programme to supplement the preceptorship of newly qualified nurses. The broad aims of the programme were to support the nurses in making the transition from novice to expert, to aid recruitment and retention of staff within acute inpatient areas, and to improve the standard and consistency of care provided. Our experience suggests that all these aims were met, newly qualified staff felt supported in becoming competent, confident practitioners and the group played an important role in developing a healthy and supportive ward culture.

Cardiovascular disease in late survivors of tetralogy of fallot: a tertiary care center experience.

Patients with tetralogy of Fallot can survive to late adulthood; however, there are few data on cardiovascular outcomes in this population. We conducted a single-center retrospective analysis of cardiovascular outcomes and risk factors in 208 patients with tetralogy of Fallot to better evaluate the burden of cardiovascular disease in this group. Descriptive statistics were used to determine the prevalence of relevant cardiovascular risk factors and outcomes, including a composite analysis of cardiovascular disease. Rates and mean values from the American Heart Association 2011 Heart Disease and Stroke Statistics Update were used as population estimates for comparison. In tetralogy of Fallot patients, cardiovascular disease prevalence was not different from that found in the general population (40% vs. 36%, P=0.3). However, there was significantly more cardiovascular disease in tetralogy of Fallot men aged 20 to 39 years (30% vs. 14%, P < 0.05) and in tetralogy of Fallot men aged 40 to 59 years (63% vs. 29%, P < 0.0001). This was due to higher prevalence of coronary disease (12% vs. 7%, P < 0.05) and heart failure (16% vs. 2%, P < 0.0001). In particular, the increased prevalence of heart failure (regardless of pulmonary valve disease) accounts for the frequency of cardiovascular disease in tetralogy of Fallot men aged 20 to 59 years. These data support the need to routinely screen young adult male survivors of tetralogy of Fallot for asymptomatic heart failure. Further studies are needed to determine the incidence, severity, and long-term effects of cardiovascular disease in the adult congenital heart disease population.

The future of the healthcare supply chain.

To achieve savings in the healthcare supply chain, healthcare organizations need to cooperate instead of compete. By forming a consolidated service center (CSC), healthcare organizations can centralize their contracting, procurement, distribution, and logistical operations. The CSC would enable organizations to improve efficiency and reduce costs.