Long-term care planning and the influencing factors among sexual minority older women: A qualitative study.

AIMS: The aim of the study was to explore plans, considerations and factors influencing long-term care among older sexual minority (SM) women. DESIGN: Qualitative interview study. METHODS: Semi-structured in-depth interviews were conducted with 37 older Taiwanese SM women between May and September 2019. This study analysed interview data using a socio-ecological model and constant comparative analysis. RESULTS: The most frequently reported long-term care plans were housing and institutions, private medical or long-term care insurance, financial planning and medical decisions. Factors associated with women's long-term care plans were categorized using the socio-ecological model level: (1) intrapersonal factors: current physical and mental health status, ageing signs and women's attitudes towards ageing; (2) interpersonal-level factors: receiving support from partners, child(ren), siblings or significant others, concerns about being a caregiver for parents and worries regarding social isolation; (3) community-level factors: receiving support from lesbian, gay, bisexual and transgender (LGBT) organizations; private lesbian online groups; or religious groups; (4) societal-level factors: concerns about negative social environments, concerns about the healthcare system and healthcare providers, inappropriate policies and insufficient resources. CONCLUSION: This study identified multi-level factors related to long-term care plans and concerns among older Taiwanese SM women. Recommendations for nurses, managers of long-term care and healthcare settings, policymakers, and governments have been provided to diminish health disparities and reduce anxiety among older SM women. IMPACT: This study assists nurses in understanding older SM women's long-term care concerns and worries when accessing long-term care and healthcare services and helps nurses provide SM-sensitive services and care for women. PATIENT OR PUBLIC CONTRIBUTION: SM older women were recruited from LGBT organizations, LGBT-friendly bookstores, restaurants, coffee shops and LGBT online chatrooms using purposive and snowball sampling.

Positive Perceptions Towards Virtual Didactics During The COVID-19 Pandemic: A Survey Assessment of Dermatology Residents.

BACKGROUND: During the COVID-19 pandemic, resident didactics at many institutions, including ours, were transitioned from in-person to virtual. OBJECTIVES: We aimed to assess dermatology residents' satisfaction, impression of effectiveness, and preference for virtual didactics, and factors correlating with these sentiments. METHODS: Questionnaire administered to dermatology residents at our institution 3-6 months following transition to virtual didactics. RESULTS: Response rate was 26/31 residents (83.9%), with 20/26 (76.9%) expressing satisfaction, 15/26 (57.7%) effectiveness, and 12/26 (46.2%) preference towards virtual didactics. Factors associated with satisfaction included feeling that virtual didactics positively impacted learning retention, represented time well spent, and utilized high-quality images. Perception of effectiveness correlated with using high-quality images, baseline preference for online instruction, and feeling engaged. Factors associated with preference for virtual didactics included having opportunities for critical thinking, using high-quality images, and utilizing images applicable to teledermatology care. Advantages to virtual didactics included convenience, decreased commuting, and easily hosting guest lecturers. Disadvantages included distractions/decreased focus, reduced social interaction, and difficulty with communication. CONCLUSIONS: Residents expressed satisfaction, effectiveness, and some preference towards virtual didactics, which correlated with numerous factors. Our findings suggest that it is reasonable to maintain a virtual didactic component as part of dermatology resident education. Furthermore, our data provide insights into strategies that residency program directors and educators may consider when/if integrating virtual didactics into future educational curricula.

Enhancing cultural competence in caring for lesbian, gay, bisexual, and transgender patients: An online training program for Taiwanese student nurses and nurses.

BACKGROUND: Health disparities exist among lesbian, gay, bisexual, and transgender (LGBT) populations worldwide. However, student nurses and nurse staff have limited knowledge and skills in providing culturally competent nursing care for LGBT patients in Taiwan. OBJECTIVES: This paper describes the development, implementation, and evaluation of an online training program for the cultural competence of student nurses and nurses in Taiwan. DESIGN: A one-group pre-/post-test study design. SETTINGS: The study was conducted in five nursing schools, 10 nursing associations, and 37 long-term care facilities. Two prominent online bulletin boards (PTT Nurse and Dcard Nurse) and one Taiwanese nursing group on Facebook were used to recruit participants. PARTICIPANTS: In total, 301 student nurses and nurses participated in the study and responded to pre- and post-test questionnaires. METHODS: An online training program for culturally competent nursing care was developed and implemented. The pre- and post-test questionnaires contained three sections: (1) demographics, (2) knowledge of LGBT health, and (3) the Sexual Orientation Counselor Competency Scale. Three open-ended questions were included in the post-test questionnaire to evaluate the online training program. RESULTS: The online training program significantly improved the participants' knowledge and cultural competence skills. However, their attitudes towards cultural competence did not change after the program was implemented. Regarding qualitative feedback of the online training program, feedback on the strengths and limitations of the program was summarized under three themes: program content, website design, and online modules. CONCLUSIONS: The results suggest the importance of an online training program which may contribute to reducing health disparities among the LGBT population.

Factors associated with providers' culturally competent care for sexual and gender minority older adults in Taiwan: A qualitative study applying the social ecological model.

BACKGROUND: Sexual and gender minority older adults receive less social support than does the general population, leading to reliance on long-term care services. On May 24, 2019, Taiwan became the first country in Asia to legalise same-sex marriage. Sexual and gender minority older adults are becoming more visible in Taiwanese society. However, healthcare providers' behaviour and intention to offer culturally competent care to sexual and gender minority older adults and factors affecting their behaviour and intention in Asian culture remain unclear. OBJECTIVE: This study determined factors associated with healthcare providers' behaviour and intention to offer culturally competent care to Taiwanese sexual and gender minority older adults and identified related training requirements. DESIGN: A qualitative descriptive study was conducted. SETTING(S): This study recruited participants from 14 lesbian, gay, bisexual, and transgender organisations; long-term care facilities; and community healthcare centres. This study was approved by the Research Ethics Committee of National Taiwan University Hospital (Ref. 201811049RIND). PARTICIPANTS: A total of 25 providers were interviewed: 12 nurses, 10 social workers, and 3 staff members from lesbian, gay, bisexual, and transgender organisations. METHODS: Semistructured interviews were conducted between May 2019 and September 2019. Interview data were analysed using the socio-ecological model and the constant comparative technique. FINDINGS: Factors associated with the providers' behaviour and intention to offer culturally competent care to sexual and gender minority older adults were categorised by the socio-ecological model level: 1) intrapersonal factors, namely providers' attitudes towards sexual and gender minority older adults, knowledge regarding sexual and gender minority populations, and experiences of providing care for sexual and gender minority older adults; 2) interpersonal factors, namely providers' concerns regarding interactions among staff, sexual and gender minority older adults, nonsexual and gender minority residents, and nonsexual and gender minority residents' families; 3) community factors, namely resources, training courses, and support from managers and organisations; and 4) societal factors, namely social environment and policies. CONCLUSIONS: This study identified multilevel factors associated with the providers' cultural competence in caring for sexual and gender minority older adults in Taiwan. These factors may lead to disparities in quality of life and health for sexual and gender minority older adults. Recommendations to address multilevel barriers to reduce health disparities and improving quality of life in sexual and gender minority older adults have been provided.

Should the non-operative management of appendicitis be the new standard of care?

Appendicitis is one of the most commonly encountered emergency presentations to the general surgical services. The operative management of this condition is associated with significant financial costs and represents a significant workload on the emergency surgical services. Negative appendicectomy rates remain high (20-25%) despite advancements in laboratory testing and imaging techniques. Recent data from randomized controlled trials suggests that non-operative management in patients presenting with uncomplicated or non-perforated acute appendicitis is a viable alternative, with only 23% of patients requiring an appendicectomy at 1 year and an overall reduction in complications. In view of this, the traditional teaching of mandatory appendicectomy for all patients with acute appendicitis should be challenged. This article briefly reviews the evidence that supports the use of diagnostic tests to reduce the negative appendicectomy rate and examines the potential selection criteria for non-operative management. The data raises the questions: can a 20-25% negative appendicectomy rate be defended as best practice and can the traditional dogma of early appendicectomy to prevent perforation be supported?

Respiratory failure following delayed intrathecal morphine pump refill: a valuable, but costly lesson.

BACKGROUND: Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. OBJECTIVE: To describe a severe adverse event, i.e., respiratory failure, following delayed intrathecal morphine pump refill. CASE REPORT: A 65-year-old woman with intractable chronic low back pain, due to degenerative disc disease, and was referred to our clinic for an intraspinal drug delivery evaluation, after failing to respond to multidisciplinary pain treatment. Following a psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine infusion trial. The infusion trial lasted 12 days and was beneficial in controlling her pain. The patient reported more than 90% pain reduction with improved distance for ambulation. She subsequently consented and was scheduled for permanent intrathecal morphine pump implantation. The intrathecal catheter was inserted at right paramedian L3-L4, with catheter tip advanced to L1, confirmed under fluoroscopy. Intrathecal catheter placement was confirmed by positive CSF flow and by myelogram. A non-programmable Codman 3000 constant-flow rate infusion pump was placed in the right mid quandrant between right rib cage and right iliac crest. The intrathecal infusion consisted of preservative free morphine, delivering 1.0 mg /day. Over the following 6 months, the dosage was gradually titrated up to 4 mg/day with satisfactory pain control without significant side effects. However, the patient was not able to return to the clinic for pump refill until 12 days later than the previously scheduled pump-refill date. Her pump was accessed and was noted to be empty. Her intrathecal pump was refilled with preservative free morphine, delivering 4 mg/day (the same daily dose as her previous refill). However, on the night of pump refill, 10 hours after the pump refill, the patient was found to be unresponsive by her family members. 911 was called. Upon arriving, paramedics found her in respiratory failure, with shallow breathing at a rate of 5/min, pulse oxymetry showing oxygen saturation about 55-58%. She was emergently intubated on site and rushed to local hospital ER. The on call physician for our clinic was immediately contacted, and advised the administration of intravenous Naloxone. Her respiratory effort improved dramatically after receiving a total of 0.6 mg IV Naloxone IV over 25 minutes. Her intrathecal pump was immediately accessed by clinic on call physician and the remainder of the medication in the catheter space was aspirated. The pump infusate was immediately diluted with preservative free normal saline, to deliver preservative free morphine at 1mg/day. She was transferred to the intensive care unit and extubated the next morning. She recovered fully without any sequelae. CONCLUSION: Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type.

School design and physical activity among middle school girls.

Building design and grounds might contribute to physical activity, and youth spend much of their daylight hours at school. We examined the associations among school building footprints, the size of school grounds, and in-school physical activity of 1566 sixth-grade girls from medium to large middle schools enrolled in the Trial of Activity for Adolescent Girls (TAAG). The school building footprint and the number of active outdoor amenities were associated with physical activity among adolescent girls. On average, the school footprint size accounted for 4% of all light physical activity and 16% of all MET-weight moderate-to-vigorous physical activity (MW-MVPA) during school hours. Active outdoor amenities accounted for 29% of all MW-MVPA during school. School design appears to be associated with physical activity, but it is likely that programming (eg, physical education, intramurals, club sports), social factors, and school siting are more important determinants of total physical activity.