Quality of care for people with multimorbidity - a case series.

BACKGROUND: Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. METHODS: To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients' medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. RESULTS: The review of the patients' records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. CONCLUSIONS: Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.

Subacute fat-embolism-like syndrome following high-volume intramuscular and accidental intravascular injection of mineral oil.

OBJECTIVE: We present a rare case of subacute fat-embolism-like syndrome (FES-like) following intravascular injection of mineral oil-steroid solution with delayed diagnosis, acute onset of pulmonary distress, and transient clinical deterioration. CASE REPORT: A 40-year-old man was admitted following as a pedestrian being hit by a car. Examinations revealed sternum fracture and lung contusion. The patient was discharged with oral analgesics. Seven days later he returned presenting with coughing, hemoptysis, elevated leucocytes, and increased C-reactive protein. Chest radiograph revealed basal infiltrations. Suspecting pneumonia, the patient was discharged with antibiotics. Unknown to the clinicians, the patient had self-administered a mineral oil with added anabolic steroids by intramuscular injections for cosmetic purposes. The patient had observed blood on aspiration, and then relocated the needle before injecting 140 ml in his biceps muscle. Shortly after, the patient described near fainting and hemoptysis suggesting an accidental intravascular injection. Over the next 3 days the patient experienced increasing shortness of breath and hemoptysis. Examinations confirmed the diagnosis and the patient was treated with organ-specific supportive measures, tranexamic acid, and prednisolone and discharged after 11 days in the hospital. CONCLUSION: Subacute FES-like was associated with injection of body filler in muscle tissue. FES-like can mimic pneumonia, posttraumatic lung injury, and other more frequent causes to respiratory failure.

[Hereditary haemorrhagic telangiectasia diagnosed in connection with a traffic accident]. / Morbus Osler diagnosticeret hos 16-årig i forbindelse med en trafikulykke.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by vascular dysplasia and haemorrhage. It is manifested by mucocutaneous telangiec-tases and arteriovenous malformations in organs such as lungs, liver and brain. We present a case of HHT. A 16-year-old patient with a history of recurrent epistaxis was admitted to the local hospital with chest pain and desaturation. A CT scan revealed pulmonary arteriovenous malformations.