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BACKGROUND: Recent data indicate rising opioid overdose deaths among African American residents of Washington, DC. OBJECTIVES: We highlight a community-informed approach to assessing attitudes toward opioid use disorder treatment among DC residents (February 2019 to March 2020). METHODS: A listening tour with trusted community leaders led to the formation of a Community Advisory Board (CAB). When the COVID-19 pandemic commenced in March 2020, community dialogues became exclusively virtual. The CAB partnered with academic leaders to co-create project mission and values and center the community's concerns related to opioid use and its causes, treatment structure, and facilitators of effective engagement. RESULTS: Interview guides were created for the engagement of community members, using values highlighted by the CAB. The CAB underscored that in addition to opioid problems, effective engagement must address community experience, collective strengths/resilience, and the role of indigenous leadership. CONCLUSIONS: Engaging community prior to project implementation and maintaining alignment with community values facilitated opioid use disorder assessments. Community-informed assessments may be critical to building community trust.
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Negro o Afroamericano , COVID-19 , Investigación Participativa Basada en la Comunidad , Trastornos Relacionados con Opioides , Humanos , Negro o Afroamericano/psicología , District of Columbia/epidemiología , COVID-19/epidemiología , Femenino , Masculino , SARS-CoV-2 , Participación de la Comunidad/métodos , AdultoRESUMEN
Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.
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BACKGROUND Inherited deficiencies in the FBN1 gene, which encodes fibrillin-1, result in Marfan syndrome, an autosomal dominant connective tissue disorder that is associated with aortic root dilatation and predisposes to aortic dissection. This report is of a 37-year-old woman presenting at 39 weeks of pregnancy with acute thoracic aortic dissection due to previously undiagnosed FBN1-related Marfan syndrome. This case report aims to illustrate the challenges in the diagnosis and in the peri-operative management of acute aortic dissection during pregnancy. CASE REPORT A healthy 37-year-old woman at 39 weeks of gestation presented to our hospital with dyspnea and chest pain. Initial evaluation for pulmonary embolism with chest computed tomography was unrevealing. The patient was admitted to the intensive care unit for further management. Overnight, her clinical conditions deteriorated, and a transthoracic echocardiography was obtained, demonstrating an acute ascending aortic dissection. She emergently underwent a successful combined cesarean section and ascending aortic dissection repair, with no immediate complications. On postoperative day 4 she developed cardiac tamponade, for which she underwent emergent mediastinal exploration. She was discharged home on postoperative day 10. A month later she completed genetic testing, which revealed a pathogenic mutation in the FBN1 gene, consistent with a molecular diagnosis of Marfan syndrome. CONCLUSIONS This report has shown that FBN1-related Marfan's syndrome has a variable clinical presentation that can include life-threatening aortic dissection during pregnancy. Successful diagnosis and management of these patients is challenging and requires multidisciplinary expertise, including confirmation of the diagnosis by a clinical geneticist.
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Disección Aórtica , Disección de la Aorta Ascendente , Síndrome de Marfan , Femenino , Embarazo , Humanos , Adulto , Síndrome de Marfan/complicaciones , Síndrome de Marfan/diagnóstico , Cesárea , Fibrilina-1/genética , Disección Aórtica/diagnóstico , Disección Aórtica/etiología , Disección Aórtica/cirugíaRESUMEN
Orthopedic fractures in adults 65 and older are common and can lead to functional decline and increased morbidity and mortality. Falls are often the precipitating event for fractures in this population, linked to common aging physiology with increasing comorbid conditions and advancing frailty. Managing falls and orthopedic fractures in the geriatric population is complex, requiring a systematic and collaborative approach spearheaded by a multidisciplinary team focused on improving patient outcomes.
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Fracturas Óseas , Fracturas de Cadera , Ortopedia , Adulto , Humanos , Anciano , Morbilidad , Evaluación GeriátricaRESUMEN
A 58-year-old man without any personal or familial cardiac history presented to the emergency department with complaints of worsening left-sided chest pain that began at rest, described as a burning sensation and escalating to a 9/10 severity. He denied any personal or familial cardiac history but admitted that he had not been medically evaluated in approximately five years. His physical examination was notable for obesity, xerosis, macroglossia, and bilateral lower extremity edema. His initial labs demonstrated critical troponin levels that peaked at 11.5 ng/mL and he was diagnosed with a myocardial infarction and underwent cardiac catheterization with percutaneous stenting of the left anterior descending artery. His post-operative period was complicated by prolonged lethargy that was determined to be myxedema coma two days later when his thyroid stimulating hormone level was found to be 78 mIU/mL.
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An immunocompetent 45-year-old Cuban-American man presented with worsening knee pain and swelling despite antibiotic therapy. On physical examination, the patient was ill-appearing, cachectic, with a protuberant abdomen and massive splenomegaly. In addition, he had a 10 cm area of peripheral hyperemia with central necrosis in the medial left knee that was non-tender and non-fluctuant. Initial lab work demonstrated pancytopenia, hyponatremia, hypoalbuminemia, and anemia of chronic inflammation. Peripheral smear showed microcytic, hypochromic red blood cells with mild anisopoikilocytosis. and leukopenia with slight left shift and metamyelocytes. Bone marrow biopsy demonstrated amastigotes and kinetoplasts within white blood cells and extracellular space consistent with leishmaniasis. Centers for Disease Control and Prevention (CDC) testing with PCR returned positive for Leishmaniasis infantum. The patient received two courses of amphotericin B lipid complex (ABLC) with a 28-day course of miltefosine, which resulted in clinical improvement. This case illustrates the unique pathology that can affect immigrants and highlights the need to increase health provider awareness of foreign pathologies in areas with large migrant populations.
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PURPOSE: This study assessed whether personality testing of postgraduate year 1 (PGY1) pharmacy residency applicants was feasible and predicted important selection outcomes, including interview offers. METHODS: Applicants to the PGY1 pharmacy residency program at a large academic medical center were invited to complete a 50-item online personality test based on the 5-factor model (ie, the "Big Five"). Scores were sealed until after matching, at which point they were compared to screening, interview, and ranking and match outcomes. Endpoints of interest included the feasibility of the test (eg, time required for completion, completion rate) and whether personality predicted the odds of an interview offer. RESULTS: The personality test was taken by 137 PGY1 applicants (69.5%) and required a median of 6.8 minutes to complete. Openness to experience was associated with decreased odds of an interview offer (adjusted odds ratio [OR], 0.86; 95% confidence interval [CI], 0.75-0.98), whereas conscientiousness and extraversion were associated with increased odds of an interview offer (conscientiousness: adjusted OR, 1.26; 95% CI, 1.02-1.55; extraversion: OR, 1.16; 95% CI, 1.03-1.31). When combined with traditional screening criteria (eg, awards, leadership positions), openness to experience and extraversion remained predictors of an interview offer (in the directions specified above), whereas conscientiousness did not. In an exploratory analysis of interviewees, agreeableness was a negative predictor of interview score. Personality did not predict screening scores or final ranking. CONCLUSION: Personality testing, based on the traits desired at individual residency programs, could be a valuable addition to the methods used for selecting PGY1 pharmacy residents.
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Residencias en Farmacia , Farmacia , Estudiantes de Farmacia , Humanos , Liderazgo , PersonalidadRESUMEN
This paper details U.S. Research Centers in Minority Institutions (RCMI) Community Engagement Cores (CECs): (1) unique and cross-cutting components, focus areas, specific aims, and target populations; and (2) approaches utilized to build or sustain trust towards community participation in research. A mixed-method data collection approach was employed for this cross-sectional study of current or previously funded RCMIs. A total of 18 of the 25 institutions spanning 13 U.S. states and territories participated. CEC specific aims were to support community engaged research (94%); to translate and disseminate research findings (88%); to develop partnerships (82%); and to build capacity around community research (71%). Four open-ended questions, qualitative analysis, and comparison of the categories led to the emergence of two supporting themes: (1) establishing trust between the community-academic collaborators and within the community and (2) building collaborative relationships. An overarching theme, building community together through trust and meaningful collaborations, emerged from the supporting themes and subthemes. The RCMI institutions and their CECs serve as models to circumvent the historical and current challenges to research in communities disproportionately affected by health disparities. Lessons learned from these cores may help other institutions who want to build community trust in and capacities for research that addresses community-related health concerns.
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Participación de la Comunidad , Grupos Minoritarios , Estudios Transversales , Humanos , Proyectos de Investigación , ConfianzaRESUMEN
Efforts to move community engagement in research from marginalized to mainstream include the NIH requiring community engagement programs in all Clinical and Translational Science Awards (CTSAs). However, the COVID-19 pandemic has exposed how little these efforts have changed the dominant culture of clinical research. When faced with the urgent need to generate knowledge about prevention and treatment of the novel coronavirus, researchers largely neglected to involve community stakeholders early in the research process. This failure cannot be divorced from the broader context of systemic racism in the US that has contributed to Black, Indigenous, and People of Color (BIPOC) communities bearing a disproportionate toll from COVID-19, being underrepresented in COVID-19 clinical trials, and expressing greater hesitancy about COVID-19 vaccination. We call on research funders and research institutions to take decisive action to make community engagement obligatory, not optional, in all clinical and translational research and to center BIPOC communities in this process. Recommended actions include funding agencies requiring all research proposals involving human participants to include a community engagement plan, providing adequate funding to support ongoing community engagement, including community stakeholders in agency governance and proposal reviews, promoting racial and ethnic diversity in the research workforce, and making a course in community engaged research a requirement for Masters of Clinical Research curricula.
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Pressure to reduce health care costs, limited hospital bed availability as well as improvements in surgical techniques and perioperative care motivated many health care centres to implement short-stay protocols for patients undergoing hip or knee arthroplasty. To improve patient outcomes and maintain care safety, we strongly believe the best way to implement a successful outpatient program would be to embrace the principles of Enhanced Recovery After Surgery (ERAS), and to improve patient recovery to a level such that the patient could leave the hospital sooner. Enhanced Recovery Canada and the Canadian Patient Safety Institute support the development of ERAS pathways for orthopedic procedures. The goal is to provide patients, health care providers and leaders with helpful tools and resources to effectively implement and sustain ERAS protocols. Reducing the rate of adverse events while reducing the length of hospital stays to less than 24 hours is a winning situation for everyone.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Recuperación Mejorada Después de la Cirugía , Tiempo de Internación/estadística & datos numéricos , Protocolos Clínicos , HumanosRESUMEN
BACKGROUND: Women who engage in higher levels of exercise while trying to quit smoking have been shown to be less likely to relapse and to sustain their smoking abstinence longer. This study sought to examine the benefits of exercise for improving smoking cessation among Black women. METHODS: We evaluated the feasibility of a 12-week smoking and exercise intervention, Quit and Fit, tailored for Black women. All participants (intervention and control) received 12 weeks of smoking cessation counseling via telephone and 9 weeks of nicotine lozenges. Participants who were randomly assigned to the intervention condition were also assigned to a 12-week exercise group. RESULTS: Thirty-eight women were enrolled and 27 completed a 12-week follow-up assessment. Women from the intervention group were more likely to complete the 12-week follow-up assessment compared to participants in the control group (80% vs. 61%). Overall, 7 of the 38 participants (18%) were abstinent at 12 weeks (biochemically verified by expired carbon monoxide). Among the 25 women who completed the 12-week follow-up, abstinence was reported in 33% of the intervention group and 20% of the control group. Using an intent-to-treat approach, 25% of women in the intervention group were abstinent at 12 weeks (n = 5), compared to 11.1% for the control group (n = 2). These differences were not statistically significant. CONCLUSIONS: The overall retention rate was 71% (27/38) at 12 weeks with higher among the intervention group (16/20; 80%) compared to the control group (11/18; 61%). The study demonstrates that it is feasible to retain African-American women in a short-term study of smoking cessation and exercise.
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Cese del Hábito de Fumar , Negro o Afroamericano , Terapia por Ejercicio , Estudios de Factibilidad , Femenino , Humanos , FumarRESUMEN
Background and study aims Negative experiences with bowel preparation are a barrier to uptake of colonoscopy. The aim of this study was to examine the impact of different flavoring of polyethylene glycol (PEG) laxatives on patient satisfaction with and adequacy of bowel preparation during colonoscopy. Patients and methods This was a single-blind (endoscopist), parallel design, randomized trial (NCT02062112) during which patients scheduled for colonoscopy were assigned to one of three groups: Group 1 (no laxative flavoring, nâ=â84); Group 2 (flavored entire laxative, nâ=â90) and Group 3 (tasted PEG with and without flavoring and decided how they want to drink the rest of the laxatives (choice group), nâ=â82). Patients rated their bowel preparation experience (satisfaction) and endoscopists accessed adequacy of bowel preparation during colonoscopy. Results There were no differences in patient ratings across the groups (1, 2 and 3) in taste of the laxatives ( P â=â0.67), ease of drinking ( P â=â0.53), and overall experience of bowel preparation process ( P â=â0.18). However, higher percentage of patients in the choice group would want the same laxative again if they were going to have a repeat colonoscopy in the future (72.5â% vs 81.3â% vs 88.9â%, P â=â0.04). Surprisingly, adequacy of bowel preparation was highest among patients who drank their PEG unflavored (89.3â% vs 80â% vs 75.5â%, P â=â0.07) and the had highest rates of adenoma detection (40.5â% vs 23.3 vs 39.0, P â=â0.03). Conclusions There were no differences in overall tolerability of bowel preparation by patterns of flavoring of PEG. Those who drank unflavored PEG were less satisfied but had better clinical outcome, suggesting minimum justification effect in bowel preparation process.
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OBJECTIVE: Insomnia is a significant concern among African-American breast cancer survivors (BCS). Social constraints (SC)-receiving unsupportive or critical responses when expressing trauma-related emotions-and fear of recurrence (FOR) have been associated with insomnia. We examined FOR as a mediator in the relationship between SC and insomnia in African-American BCS. We hypothesized a direct effect of SC on insomnia, and an indirect effect of SC on insomnia through FOR. METHODS: Sixty-four African-American BCS completed a questionnaire assessing demographics, clinical characteristics, SC, FOR, and insomnia. Participants were an average of M = 8.41 (SD = 5.8) year survivors. The mediation was tested using PROCESS for SPSS. RESULTS: The direct effect of SC on insomnia was significant (direct effect = .17, SE = .08, P = .04). Moreover, the indirect effect of SC on insomnia through FOR was significant (indirect effect = .19, SE = .10, 95% CI = .05, .41). CONCLUSIONS: Experiencing SC from family and friends could produce cognitions that impact sleep for BCS, and FOR could be one of those cognitions. Family-based models of care that emphasize the emotional needs of survivors and families could be a relevant strategy to address the SC that impacts sleep.
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Negro o Afroamericano/psicología , Neoplasias de la Mama/psicología , Supervivientes de Cáncer/psicología , Miedo/psicología , Recurrencia Local de Neoplasia/psicología , Trastornos del Inicio y del Mantenimiento del Sueño/psicología , Adulto , Neoplasias de la Mama/etiología , Cognición , Femenino , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/etiología , Sueño , Trastornos del Inicio y del Mantenimiento del Sueño/etiología , Encuestas y CuestionariosRESUMEN
Patients undergoing surgery today experience longer hospital stays and more complications because evidence-based practices in the areas of nutrition, activity, opioid-sparing analgesia, hydration and overall best practices are not consistently applied or used. There is also emerging evidence that supporting patients and families to become engaged in their perioperative care improves outcomes. Enhanced Recovery After Surgery (ERAS) helps patients be more prepared for surgery and recover more quickly by bringing patients, healthcare providers and health systems together and creating tools and resources that are based on the most up-to-date evidence. The goal of Enhanced Recovery Canada is to support the uptake of these best practices across Canada, improving patient outcomes and experiences.
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Recuperación Mejorada Después de la Cirugía , Atención Perioperativa/métodos , Complicaciones Posoperatorias/prevención & control , Canadá , Vías Clínicas , Práctica Clínica Basada en la Evidencia , Humanos , Seguridad del PacienteRESUMEN
Use of community-based participatory research (CBPR) principles can help identify strategies for development and implementation of studies that can address oral health disparities disfavoring African American youth. This paper summarizes approaches of the Howard Meharry Adolescent Caries Study (HMACS) to provide sustained oral health services beyond the life of a research study.
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Negro o Afroamericano , Investigación Participativa Basada en la Comunidad/organización & administración , Caries Dental/etnología , Salud Bucal , Servicios de Salud Escolar/organización & administración , Adolescente , Caries Dental/etiología , Promoción de la Salud , Disparidades en Atención de Salud/etnología , Humanos , Odontología Pediátrica , Estados UnidosRESUMEN
Summary: Enhanced Recovery After Surgery (ERAS) is a model of care that was introduced in the late 1990s by a group of surgeons in Europe. The model consists of a number of evidence-based principles that support better outcomes for surgical patients, including improved patient experience, reduced length of stay in hospital, decreased complication rates and fewer hospital readmissions. A number of Canadian surgical care teams have already adopted ERAS principles and have reported positive outcomes. Arising from the Canadian Patient Safety Institute's Integrated Patient Safety Action Plan for Surgical Care Safety, and with support from numerous partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. We discuss the development of a multidisciplinary clinical pathway for elective colorectal surgery to help guide Canadian clinicians.
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Cirugía Colorrectal/normas , Vías Clínicas/normas , Recuperación Mejorada Después de la Cirugía/normas , Grupo de Atención al Paciente/normas , Seguridad del Paciente/normas , Canadá , Medicina Basada en la Evidencia/normas , HumanosRESUMEN
Background: Delays to definitive treatment for time-sensitive acute paediatric illnesses continue to be a cause of death and disability in the Canadian healthcare system. Our aim was to develop the SIGNS-for-Kids illness recognition tool to empower parents and other community caregivers to recognise the signs and symptoms of severe illness in infants and children. The goal of the tool is improved detection and reduced time to treatment of acute conditions that require emergent medical attention. Methods: A single-day consensus workshop consisting of a 17-member panel of parents and multidisciplinary healthcare experts with content expertise and/or experience managing children with severe acute illnesses was held. An a priori agreement of ≥85% was planned for the final iteration SIGNS-for-Kids tool elements by the end of the workshop. Results: One hundred percent consensus was achieved on a five-item tool distilled from 20 initial items at the beginning of the consensus workshop. The final items included four child-based items consisting of: (1) behaviour, (2) breathing, (3) skin, and (4) fluids, and one context-based item and (5) response to rescue treatments. Conclusions: Specific cues of urgent child illness were identified as part of this initial development phase. These cues were integrated into a comprehensive tool designed for parents and other lay caregivers to recognise the signs of serious acute illness and initiate medical attention in an undifferentiated population of infants and children. Future validation and optimisation of the tool are planned.
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Consenso , Promoción de la Salud/métodos , Tiempo de Tratamiento , Triaje/métodos , Canadá , Enfermedad Crítica , Educación/métodos , HumanosRESUMEN
Some patients have residual non-specific symptoms after therapy for Lyme disease, referred to as post-treatment Lyme disease symptoms or syndrome, depending on whether there is functional impairment. A standardized test battery was used to characterize a diverse group of Lyme disease patients with and without residual symptoms. There was a strong correlation between sleep disturbance and certain other symptoms such as fatigue, pain, anxiety, and cognitive complaints. Results were subjected to a Logistic Regression model using the Neuro-QoL Fatigue t-score together with Short Form-36 Physical Functioning scale and Mental Health component scores; and to a Decision Tree model using only the QoL Fatigue t-score. The Logistic Regression model had an accuracy of 97% and Decision Tree model had an accuracy of 93%, when compared with clinical categorization. The Logistic Regression and Decision Tree models were then applied to a separate cohort. Both models performed with high sensitivity (90%), but moderate specificity (62%). The overall accuracy was 74%. Agreement between 2 time points, separated by a mean of 4 months, was 89% using the Decision Tree model and 87% with the Logistic Regression model. These models are simple and can help to quantitate the level of symptom severity in post-treatment Lyme disease symptoms. More research is needed to increase the specificity of the models, exploring additional approaches that could potentially strengthen an operational definition for post-treatment Lyme disease symptoms. Evaluation of how sleep disturbance, fatigue, pain and cognitive complains interrelate can potentially lead to new interventions that will improve the overall health of these patients.