Identifying adolescents at risk for suboptimal adherence to tuberculosis treatment: A prospective cohort study.

Adolescents account for an estimated 800,000 incident tuberculosis (TB) cases annually and are at risk for suboptimal adherence to TB treatment. Most studies of adolescent TB treatment adherence have used surveillance data with limited psychosocial information. This prospective cohort study aimed to identify risk factors for suboptimal adherence to rifampicin-susceptible TB treatment among adolescents (10-19 years old) in Lima, Peru. We collected psychosocial data using self-administered surveys and clinical data via medical record abstraction. Applying k-means cluster analysis, we grouped participants by psychosocial characteristics hypothesized to impact adherence. Then, we conducted mixed effects regression to compare suboptimal adherence-defined as <90% (missing >10% of doses)-between clusters. Treatment setting (facility vs. home) and drug formulation (single drug vs. fixed dose combination) were interaction terms. Of 249 participants, 90 (36.1%) were female. Median age was 17 (IQR: 15, 16.6) years. We identified three clusters-A, B, and C-of participants based on psychosocial characteristics. Cluster C had the lowest support from caregivers, other family members, and friends; had the weakest motivation to complete TB treatment; were least likely to live with their mothers; and had experienced the most childhood adversity. Among the 118 (47.4%) participants who received facility-based treatment with single drug formulations, adherence did not differ between Clusters A and B, but Cluster C had six-fold odds of suboptimal adherence compared to Cluster A. In Clusters B and C, adherence worsened over time, but only in Cluster C did mean adherence fall below 90% within six months. Our findings have implications for the care of adolescents with TB. When caring for adolescents with low social support and other risk factors, clinicians should take extra measures to reinforce adherence, such as identifying a community health worker or peer to provide treatment support. Implementing newly recommended shorter regimens also may facilitate adherence.

Does destination make a difference? Outcomes after a policy change affecting cutoff times for pre-hospital transport.

BACKGROUND: Facilitating primary triage and care at Pediatric Trauma Centers (PTCs) can improve outcomes for children after trauma. However, scene location and regional EMS regulations may result in initial evaluation occurring at non-pediatric facilities with later transportation to PTCs for definitive care. In this study, we assessed the results of a change in transport time cutoff from 30 to 45 minutes on pediatric patient outcomes. METHODS: After IRB approval, the Pediatric Trauma Database at a level 1 PTC was queried for patients seen before (January 1, 2015-December 31, 2017) and after (January 1, 2018-December 31, 2020) the implementation of a policy increasing transport cutoff time from 30 to 45 minutes. Patient outcomes were compared by transport status and ISS using generalized linear regression analysis. RESULTS: 505 patients were seen pre and 413 patients post policy changes. Both groups had similar numbers of severely injured patients (ISS ≥ 15, 64 (13%) pre and 61 (15%) post). Average transport time increased post change (pre 20 min (95% CI[18,22] min), post 29 min (95% CI[26,33] min, p = 0.0252), consistent with policy compliance. The proportion of transferred patients did not change after policy implementation (p = 0.5856), and the complications among all patients with ISS ≥ 15 did not significantly decrease (pre 75%, post 65.6%). However, those patients with ISS ≥ 15 admitted directly from the scene had a lower frequency of complications after the policy changes (pre 76%, post 59%, p = 0.0319), and in the post period transferred patients with an ISS ≥ 15 had a higher complication rate than those admitted directly from the scene (p < 0.0001). CONCLUSIONS: Direct scene admission to a PTC is associated with a lower complication profile for patients with higher ISS. Methods to ensure adherence to cutoff thresholds for EMS transport may have a positive benefit on patient outcomes. LEVEL OF EVIDENCE: IV, prognostic/epidemiological.

Less qualitative multiparametric magnetic resonance imaging in prostate cancer can underestimate extraprostatic extension in higher grade tumors.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) is increasingly used for risk stratification and preoperative staging of prostate cancer. It remains unclear how Grade Group (GG) interacts with the ability of mpMRI to determine the presence of extraprostatic extension (EPE) on surgical pathology. METHODS: A retrospective review of a robotic assisted laparoscopic radical prostatectomy (RALP) database from 2016-2020 was performed. Radiology mpMRI reports by multiple attending radiologists and without clear standardization or quality control were retrospectively assessed for EPE findings and compared with surgical pathology reports. The data were stratified by biopsy-based GG and a multivariable cluster analysis was performed to incorporate additional preoperative variables (age at diagnosis, PSA, etc.). Hazard ratios were calculated to determine how mpMRI findings and radiographic EPE relate to positive surgical margins. RESULTS: 289 patients underwent at least one mpMRI prior to RALP. Preoperative mpMRI demonstrated sensitivity of 39.3% and specificity of 88.8% for pathological EPE and had a negative predictive value (NPV) of 49.5%, and positive predictive value (PPV) of 84.0%. Stratification of NPV by GG yielded the following values: GG 1-5 (49.5%), GG 3-5 (40.8%), GG 4-5 (43.4%), and GG 5 (30.4%). Additionally, positive EPE on preoperative mpMRI was associated with a significantly decreased risk of positive surgical margins (RR: 0.655; 95% CI: 0.557-0.771). CONCLUSIONS: NPV of prostate mpMRI for EPE may be decreased for higher grade tumors. A detailed reference reading and image quality optimization may improve performance. However, urologists should exercise caution in nerve sparing approaches in these patients.

Characterizing after-hours hematology/oncology clinic calls.

BACKGROUND: After-hour calls can be resource intensive and remain a significant challenge to medical practices, though they have historically been poorly or non-reimbursable services. This study reviews after-hour calls from hematology/oncology patients at a cancer center to characterize after-hour care needs, identify care gaps, and look for opportunities to improve outpatient healthcare delivery. METHODS: This descriptive, retrospective Institutional Review Board-approved study analyzed patient calls between June 2015 to February 2021 in an academic hematology/oncology practice. Data from 500 calls were reviewed and cataloged into a database including patient demographics, clinical history, and information surrounding the call (e.g., primary reason for the call, outcome of the call). Calls were also categorized as being urgent or not from a patient or provider's perspective. RESULTS: Among 500 calls, representing 398 unique patients, the average patient was 62 years old and 52% of calls were from females. Most calls were made to report symptoms (65%), followed by calls to follow-up on labs, tests, or imaging (13%), and clarifying treatment plans (10%). Oncology patients represented 67% of calls and hematology (malignant and benign) patients represented 33%. More specifically, patients with gastrointestinal cancer (25%), hematologic malignancies (24%), and thoracic cancer (13%) represented the diagnoses with the highest call volume. CONCLUSIONS: This study explores the complexity and variety of after-hour cancer patient calls. By systematically exploring patient calls, this data can provide insight into patients' needs outside of regular clinic times and help practices develop strategies to anticipate these needs, reduce after-hour call burden, and improve overall quality of care.

The Rising Incidence of Hyperinsulinemic Hypoglycemia: Connection With Maternal Health.

OBJECTIVE: Due to a perceived rise in hyperinsulinemic hypoglycemia (HH) cases over time, notably during the COVID-19 pandemic, institutional experiences between 2013 and 2021 were reviewed to evaluate trends, characteristics, and outcomes in children with HH. METHODS: Charts of all children diagnosed with HH during the study period and evaluated by Pediatric Endocrinology were reviewed. HH was defined per Pediatric Endocrine Society guidelines. Regression analysis compared rates of change in HH cases and maternal risk factors over time. RESULTS: The incidence of HH began to rise in April 2016 and became significant in March 2017 (P < .001), with a more rapid rate of rise during the first year of the COVID-19 pandemic (P < .001). Seventy-four children with HH were identified over 9 years; 43% (n = 32) were diagnosed in 2020-2021. Maternal hypertensive disorders demonstrated longitudinal association with hyperinsulinism cases (P < .001). CONCLUSION: While HH diagnoses were on the rise for much of the 9-year study period, nearly half of all infants were diagnosed during the COVID-19 pandemic in 2020 to 21. The trends in HH diagnoses correlated with maternal hypertensive disorders. More studies exploring the roles of maternal health, hypertension, and stress and development of HH in offspring are needed.

Clinical Psychosocial Risk Factors for Sex Trafficking Involvement Among Adolescent Girls.

PURPOSE: This study assessed the characteristics that place adolescent girls at greatest risk for sex trafficking involvement. It was hypothesized that girls with a greater history of risk behaviors, unstable home environments, child maltreatment, and increased psychiatric complexity would be more likely to be involved in domestic minor sex trafficking (DMST). METHODS: Retrospective chart review of two cohorts of adolescent girls, one with known DMST history, and an age-matched cohort without DMST history, was conducted. Patients came from a Child Abuse clinic and primary care clinic within a single large urban children's hospital in the Northeast United States. Multivariate clustering analysis identified two groups of patients within the sample, one sharing "low risk" traits, and one with "high risk" traits. A variable for "psychiatric complexity" and its relationship to DMST risk was assessed. Hypothesis tests of mediation were conducted. RESULTS: 44 DMST patients and 181 Primary Care patients were included in the final sample, who were then grouped into two clusters based on conceptualized "risk" characteristics. Hypothesis testing supported evidence that patients in the "high risk" group tended toward higher psychiatric complexity (p = .0016) and greater likelihood of DMST involvement (p = .0328). Patients with increased psychiatric complexity also tended towards DMST involvement, regardless of "risk" cluster (p < .0001). DISCUSSION: This study demonstrates the relationship between social characteristics, psychiatric problems, and DMST involvement. We demonstrated that adolescents with increased psychiatric complexity tend towards greater risk of DMST. These findings demonstrate the important relationship between psychiatric complexity and sexual victimization.

"I Was Here First, Why Did They Go Before Me": Examining Patients'Perceptions of Priority in a Psychometric Study of Emergency Department Triage.

INTRODUCTION: Unrealistic patient expectations for wait times can lead to poor satisfaction. This study's dual purpose was: (1) to address disparities between patients' perceived priority level and the Emergency Severity Index (ESI) assigned by emergency room triage nurses; and (2) to evaluate validity and reliability of using the Patient Perception of Priority to be Seen Survey (PPPSS) to investigate patient expectations for emergency department urgency. METHODS: A two-group pretest-posttest quasi-experimental approach compared patient urgency opinions to nurse urgency ratings with and without a scripted educational intervention. This tested how closely patient perceptions were related to triage nurse ratings. RESULTS: Reliability for the PPPSS was acceptable (reliability = 0.75). Patients who were rated lower urgency on the ESI by triage nurses tended to self-report higher urgency (rho = -0.44, P < .01). Attitudes were more consistent in the posttest patient group who were exposed to the scripted verbal description of emergency department procedures (χ2 (1, N = 352) = 8.09, P < .01). Patients who disagreed with emergency nurse scores tended to be younger on average (eg, < 40 years old; rho = 0.69, P < .01). Male identified patients tended to be rated both by nurses and themselves as higher urgency (beta = 0.18, P = .02). DISCUSSION: We recommend the PPPSS for nurses and researchers to quickly assess patient expectations. Additionally, promoting patient understanding through a scripted educational strategy about the ESI system may also result in improvements in communication between patients and nurses.

Prevalence and trends of Clostridioides difficile infection among persons requiring maintenance hemodialysis: A systematic review and meta-analysis.

OBJECTIVE: Clostridioides difficile infection (CDI) is among the most common cause of healthcare-associated infections. Persons requiring maintenance hemodialysis (MHD) are at increased risk of CDI and associated mortality compared to persons not requiring MHD. Given the clinical impact of CDI among persons requiring MHD, we aimed to quantify the burden of CDI and trends over time in this patient population. STUDY DESIGN: A systematic review and meta-analysis of studies reporting rates of CDI among persons requiring MHD in MEDLINE, Embase, Web of Science Core Collection, CINAHL, and Cochrane Central Register of Controlled Trials were performed. Searches were conducted on May 17, 2021, and March 4, 2022. RESULTS: In total, 2,408 titles and abstracts were identified; 240 underwent full text review. Among them, 15 studies provided data on rates of CDI among persons requiring MHD, and 8 of these also provided rates among persons not requiring MHD. The pooled prevalence of CDI among persons requiring MHD was 19.14%, compared to 5.16% among persons not requiring MHD (odds ratio [OR], 4.35; 95% confidence interval [CI], 2.07-9.16; P = .47). The linear increase in CDI over time was significant, increasing an average of 31.97% annually between 1993 and 2017 (OR, 1.32; 95% CI, 1.1-1.58; P < .01). The linear annual increase was similar among persons requiring and not requiring MHD (OR, 1.28; 95% CI, 1.13-1.45; P = .11). CONCLUSIONS: Persons requiring MHD have a 4-fold higher risk of CDI compared to persons not requiring MHD, and rates of CDI are increasing over time in both groups.

Increases in Ambulance Call Volume Are an Early Warning Sign of Major COVID-19 Surges in Children.

Background: Infectious diseases, including COVID-19, have a severe impact on child health globally. We investigated whether emergency medical service (EMS) calls are a bellwether for future COVID-19 caseloads. We elaborated on geographical hotspots and socioeconomic risk factors. Methods: All EMS calls for suspected infectious disease in the pediatric population (under 18 years of age) in Rhode Island between 1 March 2018 and 28 February 2022 were included in this quasi-experimental ecological study. The first of March 2020 was the beginning of the COVID-19 pandemic. We used the 2020 census tract and the most recent COVID-19 data. We investigated associations between pediatric EMS calls and positive COVID-19 tests with time series analysis and identified geographical clusters using local indicators of spatial association. Economic risk factors were examined using Poisson regression. Results: We included 980 pediatric ambulance calls. Calls during the omicron wave were significantly associated with increases in positive COVID-19 tests one week later (p < 0.001). Lower median household income (IRR 0.99, 95% CI [0.99, 0.99]; p < 0.001) and a higher child poverty rate (IRR 1.02, 95% CI [1.02, 1.02]; p < 0.001) were associated with increased EMS calls. Neighborhood hotspots changed over time. Conclusion: Ambulance calls might be a predictor for major surges of COVID-19 in children.

Efficacy of remdesivir for hospitalized COVID-19 patients with end stage renal disease.

BACKGROUND: Since the beginning of corona virus disease 2019 (COVID-19) pandemic, there has been a widespread use of remdesivir in adults and children. There is little known information about its outcomes in patients with end stage renal disease who are on dialysis. AIM: To assess the clinical outcomes with use of remdesivir in adult patients with end stage kidney failure on hemodialysis. METHODS: A retrospective, multicenter study was conducted on patients with end stage renal disease on hemodialysis that were discharged after treatment for COVID-19 between April 1, 2020 and December 31, 2020. Primary endpoints were oxygen requirements, time to mortality and escalation of care needing mechanical ventilation. RESULTS: A total of 45 patients were included in the study. Twenty patients received remdesivir, and 25 patients did not receive remdesivir. Most patients were caucasian, females with diabetes mellitus and hypertension being the commonest comorbidities. There was a trend towards reduced oxygen requirement (beta = -25.93, X 2 (1) = 6.65, P = 0.0099, probability of requiring mechanical ventilation (beta = -28.52, X 2 (1) = 22.98, P < 0.0001) and mortality (beta = -5.03, X 2 (1) = 7.41, P = 0.0065) in patients that received remdesivir compared to the control group. CONCLUSION: Larger studies are justified to study the effects of remdesivir in this high-risk population with end stage kidney disease on dialysis.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time.

OBJECTIVE: New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program. METHODS: We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications. RESULTS: A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS. CONCLUSION: The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

Implementing Coordinated Specialty Care in CMHC Youth and Young Adults with Severe Mental Illness: Preliminary Outcome Assessment.

This study assessed impact of Coordinated Specialty Care (CSC), expanded to include both first episode psychosis (FEP) and severe mental health disorders (e.g., depression, bipolar disorder, trauma) in youths attending Community Mental Health Centers (CMHCs). Eligible youth and young adults (ages 16-26 years, N = 201) were recruited from two CMHCs and assessed every 6 months. Paired sample t-tests were performed comparing pre- and post-treatment observations. Statistically significant decreases from pre to post were found in sad and anxious feelings and in days hospitalized for psychiatric emergency and increases were found in subjective health ratings and employment status. This preliminary assessment supports the effectiveness of expanded inclusion criteria for participation in the CSC model.

How curricular changes influence medical students' perceptions of basic science: A pilot study.

THEORY: The perceived value of study material may have implications on learning and long-term retention. This study compares the perceived value of basic science of medical students from schools with a traditional "2+2" curriculum and the USMLE Step 1 placed before core clerkships to those from medical schools that have undergone curricular revisions, resulting in shortened pre-clerkship curricula and administration of the USMLE Step 1 after core clerkships. HYPOTHESIS: We hypothesize that differences in curricula, particularly duration of pre-clerkship curriculum and timing of the USMLE Step 1, affect medical students' perceived value of basic science. METHODS: A twenty item anonymous questionnaire using a 5-point Likert scale was developed to assess medical students' perceptions of basic science. The questionnaire was distributed to third-year medical students across four medical schools. Generalized linear models and p-values were calculated comparing the perceived value and use of basic science between medical schools with the USMLE Step 1 before clerkships and 2-years of basic science (BC) and medical schools with the USMLE Step 1 after core clerkships and 1.5-years of basic science (AC). RESULTS: The questionnaire was distributed to 695 eligible students and completed by 287 students. Students at BC schools tended to view basic science as more essential for clinical practice than students at AC schools across both outcomes (rating independence of basic science and clinical practice, AC school mean = 2.97, BC school mean = 2.73, p = 0.0017; rating importance of basic science to clinical practice, AC school mean = 3.30, BC schools mean = 3.50, p = 0.0135). CONCLUSIONS: Our study suggests that students who have a longer basic science curriculum tend to value basic science greater than students with a shorter basic science curriculum. The timing of the USMLE Step 1 may also influence this relationship. Curricular decisions, such as reductions in pre-clerkship curricula and administration of the USMLE Step 1 after clerkships, may impact medical students' perceptions of the value of basic science to clinical practice. This can have implications on their future engagement with basic science and should be considered when modifying curriculum.

A Novel Interprofessional Palliative Care and Geriatrics Curriculum for Nephrology Teams.

BACKGROUND: The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population. OBJECTIVES: Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care. DESIGN: We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams. SETTING: This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning. PARTICIPANTS: The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work. RESULTS: Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills. CONCLUSION: Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.

Patient care without borders: a systematic review of medical and surgical tourism.

BACKGROUND: Medical tourism (MT) is an increasingly utilized modality for acquiring medical treatment for patients globally. This review assimilates the current literature regarding MT, with particular focus on the applications, ethics and economics. METHODS: A systematic review of MEDLINE and PubMed Central databases for publications relating to MT from 2005 to 2018 yielded 43 articles for this review. RESULTS: Patients seeking elective bariatric, cosmetic and orthopedic surgery abroad are motivated by significantly lower costs, all-inclusive vacation packages and reduced wait times. Complication rates as high as 56% include infection, poor aesthetic and functional outcome and adverse cardiovascular events. Cross-border reproductive care has steadily increased due to less restrictive policies in select countries; however, the depth of research on outcomes and quality of care is abysmal. Stem cell therapy promise treatments that are often not well researched and offer minimal evidence of efficacy, yet patients are drawn to treatment through anecdotal advertisements and a last sense of hope. Transplant surgery sought to decrease wait times carries many of the similar aforementioned risks and may contribute to the practice of organ trafficking in countries with high rates of poverty. Patients and countries alike are motivated by a plethora of factors to engage in the MT industry but may be doing so without accurate knowledge of the quality, safety or potential for economic gain. Safety is of utmost importance to prevent surgical complications and the spread of treatment-resistant bacteria. CONCLUSIONS: MT is growing in popularity and complexity. The lack of standardization in its definition and regulation leads to difficulty in epidemiologic and economic analysis and ethical issues of informed consent and health equity. The findings of this review may be used by the stakeholders of MT, including patients and providers, to enhance informed decision-making and quality of care.