A comprehensive assessment for community-based, person-centered care for older adults.

BACKGROUND: Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center. METHODS: A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016-2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency. RESULTS: The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL. Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55-2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09-3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12-2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04-2.10]). CONCLUSION: Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

[Endovascular treatment of non-galenic pial arteriovenous fistulas]. / Tratamiento endovascular de las fístulas arteriovenosas piales no galénicas.

INTRODUCTION AND OBJECTIVES: Pial arteriovenous fistulas are infrequent vascular malformations. They are generally congenital and their natural history is ominous. The objective of this work is to describe our experience in their endovascular management and to review the existing literature. PATIENTS AND METHODS: This is a retrospective and descriptive study of patients treated by endovascular approach during 3 years at 3 Latin-American hospitals. RESULTS: The study included 6 patients with a mean age of 22 years. One case was caused by cranial trauma. In total, 50% suffered intracranial haemorrhage and 66% developed symptoms attributable to volume effect or retrograde blood flow. Intracranial varices were identified by CT and MRI scans in 83% of cases. Digital subtraction angiography showed arteriovenous fistulas from anterior circulation in 67% of cases and deep venous drainage in 50%. One endovascular procedure was performed in 5 cases (83%), while 2 procedures were required in one case. A single embolic agent was used to occlude fistulas in 67% of cases; whilst 33% required a combination. Coils were used in 4 cases (67%) and onyx was injected in another 4 (67%). One case required stent and balloon deployment. The fistulas were uneventfully occluded in all cases. The follow-up period was one year in 5 cases and 6 months in one case. All patients remained symptom-free. CONCLUSIONS: Endovascular management can be considered as the treatment of choice. It consists in the embolisation of arterial pedicles with one or more embolic agents and should be performed as close as possible to the drainage vein, avoiding migration of the embolic agent towards the venous side.

Manejo conservador de pseudoquiste salival parotídeo postraumático: Reporte de un caso / Conservative management of post-traumatic parotid salivary pseudocyst: A case report

Debido a su compleja anatomía, las lesiones en la región bucal pueden llevar a múltiples complicaciones. Si bien el nervio facial y el conducto parotídeo pueden ser fácilmente heridos por golpes fuertes o traumatismos penetrantes de la mejilla, la lesión del conducto parotídeo es, en general, pasada por alto (especialmente en entornos de múltiples lesiones) y rara vez es reportada en la literatura. El tratamiento de estas lesiones genera controversias, ya que series cortas y estudios de casos anecdóticos reportan su efectividad desde diversos enfoques (el tratamiento no quirúrgico, la ligadura del conducto proximal con o sin medicamentos antisialorreicos, la reparación primaria con microcirugía, la creación de la fístula sialoplastía usando mucosa oral y la sustitución de injerto venoso). Reportamos un método conservador, ideado por los autores, con el objetivo de drenar y mantener funcional al conducto de Stenon en un paciente masculino que presentó pseudoquiste salival derecho como complicación de un desgarro de la parte distal de este conducto por un trauma maxilofacial causado por accidente automovilístico.

Given the complex anatomy of the mouth, injuries occurring in this region can result in multiple complications. The facial nerve and parotid duct can be easily injured by blows or trauma penetrating the cheek. Parotid duct injury is generally overlooked, especially in settings of multiple injuries. Consequently, they are rarely reported in the literature. The treatment of these injuries is very controversial. Short series and anecdotal case studies claim success with various approaches, such as non-surgical treatment, proximal duct glide with or without antisialogogue medication, primary repair with microsurgery, the creation of the fistula sialoplasty using oral mucosa and vein graft replacement. We present a conservative approach devised by the authors, with the aim of draining and maintaining Stenon's duct functional in a male patient who presented right salivary pseudocyst, as a complication from a tear of the distal part of the duct, following maxillofacial trauma caused by a car accident.