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BACKGROUND: The COVID-19 pandemic accelerated the use of telehealth. However, this also exacerbated healthcare disparities for vulnerable populations. OBJECTIVE: To explore the feasibility and effectiveness of a medical student-led initiative to identify and address gaps in patient access to digital health resources in adult primary care clinics at a safety-net academic center. METHODS: Medical students used an online HIPAA-compliant resource directory to screen for digital needs, connect patients with resources, and track outcome metrics. Through a series of Plan-Do-Study-Act (PDSA) cycles, the program grew to offer services such as information and registration for subsidized internet and phone services via the Affordable Connectivity Program (ACP) and Lifeline, assistance setting up and utilizing MyChart (an online patient portal for access to electronic health records), orientation to telehealth applications, and connection to community-based digital literacy training. RESULTS: Between November 2021 and March 2023, the program received 608 assistance requests. The most successful intervention was MyChart help, resulting in 83% of those seeking assistance successfully signing up for MyChart accounts and 79% feeling comfortable navigating the portal. However, subsidized internet support, digital literacy training, and telehealth orientation had less favorable outcomes. The PDSA cycles highlighted numerous challenges such as inadequate patient outreach, time-consuming training, limited in-person support, and unequal language assistance. To overcome these barriers, the program evolved to utilize clinic space for outreach, increase flier distribution, standardize training, and enhance integration of multilingual resources. CONCLUSION: This study is, to the best of our knowledge, the first time a medical student-led initiative addresses the digital divide with a multi-pronged approach. We outline a system that can be implemented in other outpatient settings to increase patients' digital literacy and promote health equity, while also engaging students in important aspects of non-clinical patient care.
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BACKGROUND: some patients with inflammatory bowel disease (IBD) treated with antiTNF develop drug-induced psoriasis (antiTNF-IP). Several therapeutic strategies are possible. AIMS: to assess the management of antiTNF-IP in IBD, and its impact in both diseases. METHODS: patients with antiTNF-IP from ENEIDA registry were included. Therapeutic strategy was classified as continuing the same antiTNF, stopping antiTNF, switch to another antiTNF or swap to a non-antiTNF biologic. IP severity and IBD activity were assessed at baseline and 16, 32 and 54 weeks. RESULTS: 234 patients were included. At baseline, antiTNF-IP was moderate-severe in 60 % of them, and IBD was in remission in 80 %. Therapeutic strategy was associated to antiTNF-IP severity (p < 0.001). AntiTNF-IP improved at week 54 with all strategies, but continuing with the same antiTNF showed the worst results (p = 0.042). Among patients with IBD in remission, relapse was higher in those who stopped antiTNF (p = 0.025). In multivariate analysis, stopping antiTNF, trunk and palms and soles location were associated with antiTNF-IP remission; female sex and previous surgery in Crohn´s disease with IBD relapse. CONCLUSION: skin lesions severity and IBD activity seem to determine antiTNF-IP management. Continuing antiTNF in mild antiTNF-IP, and swap to ustekinumab or switch to another antiTNF in moderate-severe cases, are suitable strategies.
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BACKGROUND: There is an unmet surgical burden among people living with rheumatic heart disease (RHD) in Uganda. Nevertheless, risk factors associated with time to first intervention and preoperative mortality are poorly understood. METHODS: Individuals with RHD who met indications for valve surgery were identified using the Uganda National RHD Registry (January 2010-August 2022). Kaplan-Meier estimates and multivariable Cox proportional hazard models were used. RESULTS: Of the cohort with clinical RHD, 64% (1452 of 2269) met criteria for an index operation. Of those, 13.5% obtained a surgical intervention, whereas 30.6% died before the operation. The estimated likelihood of first operation was 50% at 9.3 years of follow-up (95% CI, 8.1-upper limit not reached). Intervention was more likely in men vs women (hazard ratio [HR], 1.78; 95% CI, 1.21-2.64), those with postsecondary education vs primary school or less (HR, 3.60; 95% CI, 1.88-6.89), and those with a history of atrial fibrillation (HR, 2.78; 95% CI, 1.63-4.76). Surgical intervention was less likely for adults vs those aged <18 years (HR, 0.49; 95% CI, 0.32-0.77) and those with New York Heart Association Functional Class III/IV vs I/II (HR, 0.51; 95% CI, 0.32-0.83). The median preoperative survival time among those awaiting first operation was 4.6 years (95% CI, 3.9-5.7 years). History of infective endocarditis, right ventricular dysfunction, pericardial effusion, atrial fibrillation, and having surgical indications for multiple valves were associated with increased probability of death. CONCLUSIONS: Our analysis revealed a prolonged time to first surgical intervention and high preintervention death for RHD in Uganda, with factors such as age, sex, and education level remaining barriers to obtaining surgery.
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BACKGROUND: Ulcerative proctitis (UP) can have a milder, less aggressive course than left-sided colitis or extensive colitis. Therefore, immunosuppressants tend to be used less in patients with this condition. Evidence, however, is scarce because these patients are excluded from randomised controlled clinical trials. Our aim was to describe the characteristics of patients with refractory UP and their disease-related complications, and to identify the need for immunosuppressive therapies. METHODS: We identified patients with UP from the prospective ENEIDA registry sponsored by the GETECCU. We evaluated socio-demographic data and complications associated with immunosuppression. We defined immunosuppression as the use of immunomodulators, biologics and/or small molecules. We used logistic regression to identify factors associated with immunosuppressive therapy. RESULTS: From a total of 34,716 patients with ulcerative colitis, we identified 6281 (18.1%) with UP; mean ± SD age 53 ± 15 years, average disease duration of 12 ± 9 years. Immunosuppression was prescribed in 11% of patients, 4.2% needed one biologic agent and 1% needed two; 2% of patients required hospitalisation, and 0.5% underwent panproctocolectomy or subtotal colectomy. We identified 0.2% colorectal tumours and 5% extracolonic tumours. Patients with polyarthritis (OR 3.56, 95% CI 1.86-6.69; p < 0.001) required immunosuppressants. CONCLUSIONS: Among patients with refractory UP, 11% required immunosuppressant therapy, and 4.2% required at least one biologic agent.
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Colite Ulcerativa , Imunossupressores , Proctite , Sistema de Registros , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Idoso , Proctite/tratamento farmacológico , Colite Ulcerativa/tratamento farmacológico , Imunossupressores/uso terapêutico , Estudos ProspectivosRESUMO
We explored the association between the use of a hospital-based food pantry and subsequent emergency department (ED) utilization among Medicaid patients with diabetes in a large safety-net health system. Leveraging 2015-2019 electronic health record data, we used a staggered difference-in-differences approach to measure changes in ED use before vs after food pantry use. Food pantry use was associated with a 7.3 percentage point decrease per patient per quarter (95% confidence interval, -13.8 to -0.8) in the probability of subsequent ED utilization ( P = .03). Addressing food insecurity through hospital-based food pantries may be one mechanism for reducing ED use among low-income patients with diabetes.
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Diabetes Mellitus , Serviço Hospitalar de Emergência , Medicaid , Humanos , Estados Unidos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Masculino , Diabetes Mellitus/terapia , Pessoa de Meia-Idade , Adulto , Assistência Alimentar , Insegurança Alimentar , Provedores de Redes de SegurançaRESUMO
Objective: To describe the initial experience of cardiac contractility modulation (CCM) implantation in Latin America. Method: We present the first two cases in Latin America of patients with heart failure with reduced left ventricular ejection fraction (LVEF) not candidates for cardiac resynchronization therapy in whom a CCM device was implanted. Results. Results: In both patients we described improvement of the 6-minute walk test, functional class according to the NYHA and LVEF. Conclusions: The modulation of cardiac contractility is currently a treatment option for patients with heart failure in functional class III-IV, with LVEF 25-45%, and a QRS < 130 ms who are not candidates for cardiac resynchronization therapy.
Objetivo: Describir la experiencia inicial de implante de modulación de la contractilidad cardiaca (CCM) en Latinoamérica. Método: Presentamos los dos primeros casos en Latinoamérica de pacientes con insuficiencia cardiaca y fracción de eyección del ventrículo izquierdo (FEVI) reducida no candidatos a terapia de resincronización en quienes se implantó un dispositivo de CCM. Resultados: En ambos pacientes se observó mejoría en la prueba de caminata de 6 minutos, de la clase funcional según la NYHA y de la FEVI. Conclusiones: La CCM actualmente es una opción de tratamiento en pacientes con insuficiencia cardiaca en clase funcional III-IV, con FEVI del 25-45% y QRS < 130 ms que no son candidatos a terapia de resincronización cardiaca. Palabras clave: Insuficiencia cardiaca.
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Insuficiência Cardíaca , Contração Miocárdica , Humanos , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/fisiopatologia , América Latina , Masculino , Contração Miocárdica/fisiologia , Idoso , Pessoa de Meia-Idade , FemininoRESUMO
INTRODUCTION: This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care. METHODS: This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit. RESULTS: Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96). CONCLUSIONS: There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.
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Assistência Alimentar , Abastecimento de Alimentos , Humanos , Criança , Estudos Retrospectivos , Haiti , Encaminhamento e Consulta , Atenção Primária à SaúdeRESUMO
Brachybacterium sp. GU-2 was isolated from the hard coral Porites lobata found in Apra Harbor, Guam, Micronesia. This genome sequence will be beneficial to understand the role of actinomycetes in coral holobionts. The Brachybacterium genome contains several gene clusters for bioactive compounds, including antibiotics.
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BACKGROUND: Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH. METHODS: We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes. RESULTS: There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality. CONCLUSION: Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes.
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Derivação Arteriovenosa Cirúrgica , Diálise Renal , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Retrospectivos , Diálise Renal/efeitos adversos , Determinantes Sociais da Saúde , Prevalência , Resultado do Tratamento , Derivação Arteriovenosa Cirúrgica/efeitos adversosRESUMO
INTRODUCTION: Social determinants of health (SDoH) impact patients' health outcomes, yet screening methods in emergency departments (ED) are not consistent or standardized. The SDoH-related health disparities may have widened during the coronavirus 2019 (COVID-19) pandemic, especially among patients who primarily receive their medical care in EDs. We sought to identify SDoH among ED urgent care patients during the COVID-19 pandemic at an urban safety-net hospital, assess the impact of the pandemic on their SDoH, study the feasibility of SDoH screening and resource referrals, and identify preferred methods of resource referrals and barriers to accessing resources. METHODS: Research assistants screened ED urgent care patients using a validated SDoH screener, inquiring about the impact of COVID-19 on their SDoH. A printed resource guide was provided. Two weeks later, a follow-up telephone survey assessed for barriers to resource connection and patients' preferred methods for resource referrals. This study was deemed exempt by our institutional review board. RESULTS: Of the 418 patients presented with a screener, 414 (99.0%) patients completed the screening. Of those screened, 296 (71.5%) reported at least one adverse SDoH, most commonly education (38.7%), food insecurity (35.3%), and employment (31.0%). Housing insecurity was reported by 21.0%. Over half of patients (57.0%) endorsed COVID-19 affecting their SDoH. During follow-up, 156 of 234 (67%) attempted calls were successful and 36/156 (23.1%) reported attempting to connect with a resource, with most attempts made for stable housing (11.0%) and food (7.7%). Reasons for not contacting the provided resources included lack of time (37.8%) and forgetting to do so (26.3%). Patients preferred resource guides to be printed (34.0%) and sent via text message to their mobile devices (25.6%). CONCLUSION: Many urgent care patients of this urban ED reported at least one adverse SDoH, the majority of which were exacerbated by the COVID-19 pandemic. This finding further emphasizes the need to allocate more resources to standardize and expand SDoH screening in EDs. Additionally, hospitals should increase availability of printed or electronic SDoH resource guides, resource navigators, and interpreters both during and after ED visits.
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COVID-19 , Determinantes Sociais da Saúde , Humanos , Pandemias , COVID-19/epidemiologia , Assistência Ambulatorial , Serviço Hospitalar de EmergênciaRESUMO
PURPOSE: Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role. METHODS: We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program. RESULTS: Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support. CONCLUSION: Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.
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Farmácia , Provedores de Redes de Segurança , Estados Unidos , Humanos , Atenção à Saúde , Medicaid , Apoio SocialRESUMO
The aim of this study was to investigate the genomic features of a carbapenem-resistant hypervirulent Klebsiella pneumoniae (CR-hvKp) isolate (K-2157) collected in Chile. Antibiotic susceptibility was determined using the disk diffusion and broth microdilution methods. Whole-genome sequencing (WGS) and hybrid assembly were performed, using data generated on the Illumina and Nanopore platforms. The mucoid phenotype was analyzed using both the string test and sedimentation profile. The genomic features of K-2157 (e.g., sequence type, K locus, and mobile genetic elements) were retrieved using different bioinformatic tools. Strain K-2157 exhibited resistance to carbapenems and was identified as a high-risk virulent clone belonging to capsular serotype K1 and sequence type 23 (ST23). Strikingly, K-2157 displayed a resistome composed of ß-lactam resistance genes (blaSHV-190, blaTEM-1, blaOXA-9, and blaKPC-2), the fosfomycin resistance gene fosA, and the fluoroquinolones resistance genes oqxA and oqxB. Moreover, several genes involved in siderophore biosynthesis (ybt, iro, and iuc), bacteriocins (clb), and capsule hyperproduction (plasmid-borne rmpA [prmpA] and prmpA2) were found, which is congruent with the positive string test displayed by K-2157. In addition, K-2157 harbored two plasmids: one of 113,644 bp (KPC+) and another of 230,602 bp, containing virulence genes, in addition to an integrative and conjugative element (ICE) embedded on its chromosome, revealing that the presence of these mobile genetic elements mediates the convergence between virulence and antibiotic resistance. Our report is the first genomic characterization of a hypervirulent and highly resistant K. pneumoniae isolate in Chile, which was collected during the coronavirus disease 2019 (COVID-19) pandemic. Due to their global dissemination and public health impact, genomic surveillance of the spread of convergent high-risk K1-ST23 K. pneumoniae clones should be highly prioritized. IMPORTANCE Klebsiella pneumoniae is a resistant pathogen involved primarily in hospital-acquired infections. This pathogen is characterized by its notorious resistance to last-line antibiotics, such as carbapenems. Moreover, hypervirulent K. pneumoniae (hvKp) isolates, first identified in Southeast Asia, have emerged globally and are able to cause infections in healthy people. Alarmingly, isolates displaying a convergence phenotype of carbapenem resistance and hypervirulence have been detected in several countries, representing a serious threat to public health. In this work, we analyzed the genomic characteristics of a carbapenem-resistant hvKp isolate recovered in 2022 from a patient with COVID-19 in Chile, representing the first analysis of this type in the country. Our results will provide a baseline for the study of these isolates in Chile, which will support the adoption of local measures aimed at controlling their dissemination.
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COVID-19 , Infecções por Klebsiella , Humanos , Klebsiella pneumoniae , Carbapenêmicos/farmacologia , Pandemias , Chile/epidemiologia , Infecções por Klebsiella/epidemiologia , COVID-19/epidemiologia , Plasmídeos , Antibacterianos/farmacologia , beta-Lactamases/genéticaRESUMO
OBJECTIVE: Social risk screening is recommended by the American Academy of Pediatrics, but this practice is underutilized in NICUs. To address this gap in social care, we aimed to increase rates of: (1) systematic social risk screening and (2) connection with community resources, each to ≥50% over a 14-month period. METHODS: We conducted a quality improvement initiative from November 2020 to January 2022. We adapted a screening tool and used Plan-Do-Study-Act cycles to integrate screening and referral to resources into clinical workflow. Primary outcome measures included the percentage of (1) families screened and (2) connection with resources. We examined screening by maternal race/ethnicity and primary language. Process measures were (1) time from admission to screening and (2) percentage of referrals provided to families reporting unmet needs and requesting assistance. We used statistical process control to assess change over time and χ2 tests to compare screening by race/ethnicity and language. RESULTS: The rates of systematic screening increased from 0% to 49%. Among 103 families screened, 84% had ≥1, and 64% had ≥2 unmet needs, with a total of 221 needs reported. Education, employment, transportation, and food were the most common needs. Screening rates did not vary by race/ethnicity or language. Among families requesting assistance, 98% received referrals. The iterative improvement of a written resource guide and community partnerships led to increased rates of connection with resources from 21% to 52%. CONCLUSION: Leveraging existing staff, our social risk screening and referral intervention built the capacity to address the high burden of unmet needs among NICU families.
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Família , Unidades de Terapia Intensiva Neonatal , Humanos , Criança , Recém-Nascido , Apoio Social , Encaminhamento e Consulta , Programas de RastreamentoRESUMO
Endozoicomonas sp. strain GU-1 was isolated from two separate staghorn coral (Acropora pulchra) colonies collected in Guam, Micronesia. Both isolates were grown in marine broth prior to DNA extraction and Oxford Nanopore Technologies (ONT) sequencing. Genomes were approximately 6.1 Mbp in size, containing highly similar gene content and matching sets of rRNA sequences.
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Objective: Quantify and categorize by sex, age, and time spent on mechanical ventilation (MV), the decline in skeletal muscle mass, strength and mobility in critically ill patients infected with SARS-CoV-2 and requiring mechanical ventilation while at intensive care unit (ICU). Design: Prospective observational study including participants recruited between June 2020 and February 2021 at Hospital Clínico Herminda Martin (HCHM), Chillán, Chile. The thickness of the quadriceps muscle was evaluated by ultrasonography (US) at intensive care unit admission and awakening. Muscle strength and mobility were assessed, respectively, through the Medical Research Council Sum Score (MRC-SS) and the Functional Status Score for the Intensive Care Unit Scale (FSS-ICU) both at awakening and at ICU discharge. Results were categorized by sex (female or male), age (<60 years old or ≥60 years old) and time spent on MV (≤10 days or >10 days). Setting: Intensive care unit in a public hospital. Participants: 132 participants aged 18 years old or above (women n = 49, 60 ± 13 years; men n = 85, 59 ± 12 years) admitted to intensive care unit with a confirmed diagnosis of severe SARS-CoV-2 and requiring MV for more than 48 h were included in the study. Patients with previous physical and or cognitive disorders were excluded. Interventions: Not applicable. Results: Muscle thickness have significantly decreased during intensive care unit stay, vastus intermedius (-11%; p = 0.025), rectus femoris (-20%; p < 0.001) and total quadriceps (-16%; p < 0.001). Muscle strength and mobility were improved at intensive care unit discharge when compared with measurements at awakening in intensive care unit (time effect, p < 0.001). Patients ≥60 years old or on MV for >10 days presented greater muscle loss, alongside with lower muscle strength and mobility. Conclusion: Critically ill patients infected with SARS-CoV-2 and requiring MV presented decreased muscle mass, strength, and mobility during their intensive care unit stay. Factors associated with muscle mass, such as age >60 years and >10 days of MV, exacerbated the critical condition and impaired recovery.
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Objective: The emergency department (ED) is an opportune venue to screen for unmet social needs and connect patients with social services. This quality improvement study incorporates both qualitative and quantitative data to examine unmet social needs among ED patients and program implementation. Methods: From September 2020 to December 2021, an urban safety-net hospital adult ED implemented a social needs screening and referral program. Trained emergency staff screened eligible patients for 5 social needs (housing, food, transportation, utilities, employment), giving resource guides to patients who screened positive (THRIVE+). We collected screening data from the electronic health record, conducted semi-structured interviews with THRIVE+ patients and clinical staff, and directly observed discharge interactions. Results: Emergency staff screened 58.5% of eligible patients for social risk. Of the screened patients, 27.0% reported at least 1 unmet social need. Of those, 74.8% requested assistance. Screened patients reported housing insecurity (16.3%) as the most prevalent unmet social need followed by food insecurity (13.3%) and unemployment (8.7%). Among interviewed patients, 57.1% recalled being screened, but only 24.5% recalled receiving resource guides. Patients who received guides reported little success connecting with resources and supported universal guide dissemination. Staff expressed preference for warm handoff to social services. Of 13 observed discharge interactions, clinical staff only discussed guides with 2 patients, with no positive endorsement of the guides in any observed interactions. Conclusions: An ED social needs screening program can be moderately feasible and accepted. We identified housing as the most prevalent need. Significant gaps exist between screening and referral, with few patients receiving resources. Further training and workflow optimization are underway.
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Importance: Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. Objective: To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). Design, Setting, and Participants: This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. Interventions: Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. Main Outcomes and Measures: The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. Results: Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. Conclusions and Relevance: The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03919084.
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Navegação de Pacientes , Farmácia , Estados Unidos , Humanos , Feminino , Pessoa de Meia-Idade , Pacientes Internados , Medicaid , Serviço Hospitalar de EmergênciaRESUMO
Patients with gambling disorder (GD) frequently present other mental disorders, such as substance use disorder (SUDs), attention deficit/hyperactivity disorder (ADHD), mood disorders, and impulse-control disorders. We propose that GD should not be conceptualized as a single nosological entity, but rather as a gambling dual disorder (GDD). This study aims to provide further evidence of the co-occurrence of GD and other mental disorders in routine clinical practice and to identify different clinical profiles of severity. This descriptive, cross-sectional, and observational study included 116 patients with GD who were undergoing treatment in a specialized center. The MULTICAGE-CAD 4 and South Oaks gambling screen questionnaires confirmed the presence of GD in 97.4% and 100% of the patients, respectively. Other addictive behaviors such as compulsive spending, Internet, video games, or SUD (59.5%, 27.6%, 11.2%, and 13.8%, respectively) were also identified. The most used substances were tobacco (42.2%) and alcohol (5.2%). Half of the patients suffered from ADHD, 30.2% showed moderate or severe depression, and 17.2% suffered from a social anxiety problem. The majority (76.7%) also presented a phenotype with high impulsiveness. The cluster analysis identified two different clinical profiles of severity in patients with GDD. One profile showed higher severity of other mental disorders (ADHD, depression, anxiety, SUD, or insomnia), impulsivity, general psychopathological burden, and disability. In conclusion, our study provides further evidence on the co-occurrence of GD and other mental disorders supporting the GDD existence, shows impulsiveness as a vulnerability factor for GD, and identifies two clinical severity profiles.
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Transtorno do Deficit de Atenção com Hiperatividade , Comportamento Aditivo , Transtornos Disruptivos, de Controle do Impulso e da Conduta , Jogo de Azar , Transtornos Relacionados ao Uso de Substâncias , Humanos , Jogo de Azar/epidemiologia , Estudos Transversais , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Comportamento Impulsivo , Comportamento Aditivo/diagnóstico , Comportamento Aditivo/epidemiologia , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , ComorbidadeRESUMO
BACKGROUND: We investigated outcomes of coronary artery bypass grafting (CABG) with endoscopic vein harvest (EVH) vs open vein harvest (OVH) within the Evaluation of XIENCE Versus CABG (EXCEL) trial. METHODS: All patients in EXCEL randomized to CABG were included in this study. For this analysis, the primary end points were ischemia-driven revascularization (IDR) and graft stenosis or occlusion at 5 years. Additional end points were as follows: a composite of death from any cause, stroke, or myocardial infarction; bleeding; blood product transfusion; major arrhythmia; and infection requiring antibiotics. Event rates were based on Kaplan-Meier estimates in time-to-first-event analyses. RESULTS: Of the 957 patients randomized to CABG, 686 (71.7%) received at least 1 venous graft with 257 (37.5%) patients in the EVH group and 429 (62.5%) patients in the OVH group. At 5 years, IDR was higher (11.5% vs 6.7%; P = .047) in the EVH group. At 5 years, rates of graft stenosis or occlusion (9.7% vs 5.4%; P = .054) and the primary end point (17.4% vs 20.9%; P = .27) were similar. In-hospital bleeding (11.3% vs 13.8%; P = .35), in-hospital blood product transfusion (12.8% vs 13.1%; P = .94), and infection requiring antibiotics within 1 month (13.6% vs 16.8%; P = .27) were similar between EVH and OVH patients. Major arrhythmia in the hospital (19.8% vs 13.5%; P = .03) and within 1 month (21.8% vs 15.4%; P = .03) was higher in EVH patients. CONCLUSIONS: IDR at 5 years was higher in the EVH group. EVH and OVH patients had similar rates of graft stenosis or occlusion and the composite of death, stroke, or myocardial infarction at 5 years.
Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Infarto do Miocárdio , Acidente Vascular Cerebral , Humanos , Doença da Artéria Coronariana/cirurgia , Constrição Patológica , Veia Safena/transplante , Endoscopia , Resultado do TratamentoRESUMO
(1) Scant information is available concerning the characteristics that may favour the acquisition of COVID-19 in patients with inflammatory bowel disease (IBD). Therefore, the aim of this study was to assess these differences between infected and noninfected patients with IBD. (2) This nationwide case−control study evaluated patients with inflammatory bowel disease with COVID-19 (cases) and without COVID-19 (controls) during the period March−July 2020 included in the ENEIDA of GETECCU. (3) A total of 496 cases and 964 controls from 73 Spanish centres were included. No differences were found in the basal characteristics between cases and controls. Cases had higher comorbidity Charlson scores (24% vs. 19%; p = 0.02) and occupational risk (28% vs. 10.5%; p < 0.0001) more frequently than did controls. Lockdown was the only protective measure against COVID-19 (50% vs. 70%; p < 0.0001). No differences were found in the use of systemic steroids, immunosuppressants or biologics between cases and controls. Cases were more often treated with 5-aminosalicylates (42% vs. 34%; p = 0.003). Having a moderate Charlson score (OR: 2.7; 95%CI: 1.3−5.9), occupational risk (OR: 2.9; 95%CI: 1.8−4.4) and the use of 5-aminosalicylates (OR: 1.7; 95%CI: 1.2−2.5) were factors for COVID-19. The strict lockdown was the only protective factor (OR: 0.1; 95%CI: 0.09−0.2). (4) Comorbidities and occupational exposure are the most relevant factors for COVID-19 in patients with IBD. The risk of COVID-19 seems not to be increased by immunosuppressants or biologics, with a potential effect of 5-aminosalicylates, which should be investigated further and interpreted with caution.