Prevalence and Predictors of Intimate Partner Violence Among Youth With Foster Care Histories.

A small but growing body of research suggests that adolescents and young adults involved with the child welfare system and those transitioning out of foster care are at heightened risk of experiencing intimate partner violence (IPV). Understanding the factors that place youth at risk of IPV is central to prevention and treatment of this public health problem. However, questions remain about the prevalence and correlates of IPV among youth in foster care. Additionally, emotional abuse, a particular form of IPV in intimate partnerships, remains an understudied area in this population. This study aimed to address these gaps in research by exploring factors associated with IPV using longitudinal data from a representative sample of older youth in California Foster Care who participated in the California Youth Transitions to Adulthood Study (CalYOUTH). Our IPV outcome measures included victimization, perpetration, bidirectional IPV, and emotional abuse. Findings suggest that approximately one-fifth (20.4%) of CalYOUTH respondents had experienced some form of IPV at age 23, with emotional abuse and bidirectional violence being the most commonly reported types of IPV. Females reported emotional abuse, as well as bidirectional violence, at nearly double the rates of their male counterparts. Self-identified sexual minority youth (SMY; lesbian, gay, bisexual, transgender, queer, or questioning) were more likely to report IPV victimization, IPV perpetration, and bidirectional violence than their non-SMY peers. Youth with histories of emotional abuse, caregiver IPV victimization, sexual abuse in foster care, placement instability, substance use, anxiety, and incarceration were also at heightened risk of IPV involvement. Emotional abuse was most prevalent with SMY. The findings contribute to the growing research on IPV among transition-age foster youth with important implications for future research, practice, and policy.

County-Level Factors Matter: The Role of Contextual Factors in Foster Youths' Extended Foster Care Participation and Human Capital Outcomes.

Extended foster care (EFC) is an important policy that supports human capital attainment for foster youth transitioning to adult independence. Previous studies have examined youth- and policy-level factors' influence on EFC participation and human capital outcomes (e.g., education, employment). Still, few studies have examined contextual factors (e.g., county characteristics). We explore how local contexts, or county-level attributes, influence youths' EFC participation and human capital outcomes (i.e., postsecondary education enrollment and earnings). We analyze two datasets from California Youth Transitions to Adulthood Study: survey data with rich youth-level information (n = 529) and state child welfare administrative data with a larger sample size (n = 2392). After controlling for a wide range of youth characteristics and adjusting between-county variations, regression results find that several county characteristics predict youths' EFC participation and human capital outcomes at age 21, such as political atmosphere and worker's satisfaction with cross-system collaboration. We conclude with a discussion of implications for research and practice.

Mitigating Risks of Incarceration Among Transition-Age Foster Youth: Considering Domains of Social Bonds.

Transitioning to adulthood is difficult for young people aging out of foster care. Research shows that this population faces substantial challenges in trying to avoid legal system involvement during this difficult period of life. Seeking to improve our understanding of the protective factors that mitigate the risks of legal system involvement among transition-age foster youth, this study focuses on social bonds as predictors. Drawing from social control theory and using longitudinal foster youth survey data (n = 687), we explore two domains of social bonds (interpersonal bonds, institutional bonds) youth had at the onset of adulthood (age 17), and assess the association between domains of social bonds and later incarceration in early adulthood (between ages 17 and 21). While results provide no support for the significance of interpersonal bondedness, institutional bonds were significantly associated with decreased odds of later incarceration. This suggests that social bonds may be stronger for institutional domains than for interpersonal domains in helping youth to avoid later incarceration. These findings help explain why some youth navigate the transition to adulthood better than others with regard to legal system involvement, and inform efforts to develop policy and provide services more effectively. Implications and recommendations for the field and professionals are discussed.

Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol.

INTRODUCTION: Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist. METHODS AND ANALYSIS: We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded. ETHICS AND DISSEMINATION: Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies. PROSPERO REGISTRATION NUMBER: CRD42021247756.

Voicing Individual Concerns for Engagement in Hemodialysis (VOICE-HD): A Mixed Method, Randomized Pilot Trial of Digital Health in Dialysis Care Delivery.

BACKGROUND: People receiving in-center hemodialysis (HD) have prioritized the need for more individualized health information and better communication with nephrologists. The most common setting for patient-nephrologist interactions is during the HD treatment, which is a time pressured setting that lacks privacy. OBJECTIVE: To facilitate effective communication in the hemodialysis (HD) unit, we evaluated the usability of a web application (web app) from both the patient and physician perspective. The main aim of the web app was to support patients in prioritizing their dialysis concerns outside of the clinical HD encounter. DESIGN: Mixed method, parallel arm, multi-site, pilot randomized controlled trial. SETTING: Two outpatient Canadian HD centers. PARTICIPANTS: Adult patients receiving in-center HD and their attending nephrologists. METHODS: Patients were randomized to either a web application or an active control (paper form) for logging concerns to be addressed at weekly encounters with the nephrologist over 8 weeks. Topics included: HD treatment, symptoms, modality, and medications. The primary outcome was usability, defined as effectiveness (engagement with the tool, frequency of submitted concerns, whether the concern was satisfactorily addressed) and satisfaction with the tool using a priori thresholds and explored in interviews with patients and nephrologists. RESULTS: 77 patients (30 women, median age 61, interquartile range [53,67], median 2 years [1,4] on dialysis) and 19 nephrologists (4 women, median age 46 [36,65]) were enrolled. Patient use of a digital device at baseline was low (20%). Engagement with the tool was 70% (web app) and 100% (paper) with a lower proportion of patients in the web app group submitting at least one concern over 8 weeks compared to the paper form group: 56.7% vs 87.9%. Weekly concerns were satisfactorily addressed in both groups and ≥70% of patients would continue to use the tools. For patients, both tools promoted preparation and participation in the encounter; however, only the web app facilitated greater privacy in relaying concerns. For most nephrologists, the tools were disruptive to their workflow and were perceived as unnecessary given existing processes and familiarity with patients. For future versions of the app, patients suggested more features to facilitate self-management and nephrologists suggested integration with health databases and multidisciplinary teams. LIMITATIONS: Tertiary setting may limit generalizability. CONCLUSIONS: Both tools promoted fundamental components of self-management; however, patients in the paper form group submitted concerns more often and this tool was easier to remember to use. Although modifications would likely enhance web app usability, successful future adoption is limited by physician acceptance.Trial registration ClinicalTrials.gov NCT03605875.

CONTEXTE: Les personnes qui reçoivent l'hémodialyse (HD) en center hospitalier jugent nécessaire d'obtenir des informations de santé plus individualisées et d'avoir une meilleure communication avec les néphrologues. Les interactions entre les patients et les néphrologues ont plus souvent lieu pendant l'hémodialyse, mais ce contexte manque d'intimité et les parties sont souvent pressées par le temps. OBJECTIFS: Pour aider à établir une communication plus efficace dans l'unité d'hémodialyse (HD), nous avons évalué la convivialité d'une application Web du point de vue du patient et du médecin. Cette application Web devait aider les patients à faire part de leurs préoccupations liées à la dialyze en dehors des séances d'HD. TYPE D'ÉTUDE: Essai multicentrique randomisé contrôlé avec groupes parallèles, réalisé par méthodes mixtes. CADRE: Deux centers d'hémodialyse canadiens en consultation externe. SUJETS: Des adultes recevant des traitements d'HD en center hospitalier et leurs néphrologues traitants. MÉTHODOLOGIE: Les patients ont été répartis aléatoirement pour utiliser l'application Web ou un témoin actif (formulaire papier) pour consigner, sur une période de huit semaines, les préoccupations à aborder lors des rencontres hebdomadaires avec leur néphrologue. Les sujets abordés concernaient le traitement d'HD, les symptômes, la modalité et les médicaments. Le principal critère d'évaluation était la facilité d'utilization, définie par l'efficacité (engagement avec l'outil, fréquence des soumissions, si le problème a été traité de façon satisfaisante). La satisfaction à l'égard de l'outil a été évaluée avec des seuils préétablis et explorée lors d'entrevues avec les patients et les néphrologues. RÉSULTATS: Ont été inclus 77 patients (30 femmes) sous dialyze depuis 2 ans (durée médiane; intervalle interquartile [1,4]) et dont l'âge médian s'établissait à 61 ans [53-67]. Ont aussi été inclus 19 néphrologues (4 femmes; âge médian : 46 ans [36-65]). Au début de l'étude, l'utilization d'un dispositif numérique par les patients était faible (20 %). L'engagement avec l'outil était de 70 % (application Web) et de 100 % (formulaire). Les patients du groupe « application Web ¼ sont moins nombreux à avoir soumis au moins une préoccupation au cours des huit semaines comparativement au groupe utilisant les formulaires papier (56,7 % c. 87,9 %). Les préoccupations hebdomadaires ont été abordées de façon satisfaisante dans les deux groupes et plus de 70 % des patients continueraient d'utiliser ces outils. Pour les patients, les deux outils ont favorisé la préparation et la participation à la rencontre, mais seule l'application Web a permis d'accroître la confidentialité dans la transmission des préoccupations. La plupart des néphrologues ont trouvé que ces outils perturbaient leur flux de travail et les ont perçus comme inutiles puisqu'ils jugent qu'un processus et une familiarité avec les patients existent déjà. Les patients ont suggéré que les futures versions de l'application aient plus de caractéristiques pour faciliter l'autogestion; les néphrologues ont quant à eux suggéré qu'elle soit intégrée aux bases de données sur la santé et aux équipes multidisciplinaires. LIMITES: Étude menée dans des centers de soins tertiaires, ceci pourrait limiter la généralisabilité des résultats. CONCLUSION: Les deux outils ont facilité des composantes fondamentales de l'autogestion. Cependant, les patients qui utilisaient des formulaires papier ont plus souvent fait part de leurs préoccupations. Il s'est également avéré qu'on pensait davantage à utiliser cet outil que l'application. Bien que des modifications puissent accroître la convivialité de l'application Web, son adoption demeure limitée par l'acceptation des médecins.

Predictors of remaining in foster care after age 18 years old.

BACKGROUND: The Fostering Connections to Success and Increasing Adoptions Act of 2008 created the option for U.S. states to extend the foster care age limit up to the 21 st birthday. The law provides foster youth extra protections while they transition to adulthood. OBJECTIVE: To inform states' efforts to better design and implement extended foster care (EFC), we examine the impact of the policy change on length of EFC stay and factors associated with youth's time in EFC. PARTICIPANTS AND SETTING: We use two samples of foster youth in California that extended the foster care age limit to 21 in 2012: 37,827 youths who turned 18 between the years 2008 and 2014 and 711 youths who participated in an interview-based panel study. METHODS: Leveraging California's child welfare administrative data and California Youth Transitions to Adulthood Study's (CalYOUTH) survey data, we investigated predictors of months youths remained in EFC with linear regression and Cox proportional hazard regression. RESULTS: Almost half of youth eligible for EFC remained in care until their 21 st birthday. These cohorts stayed in foster care up to 16 months longer (p < .001) than previous cohorts without an EFC option. Multiple individual factors were associated with youths' length of stay in EFC. However, a youth's county of placement made a greater difference on their time in EFC-up to 16 months (p < .05). CONCLUSIONS: Our findings underscore the importance that placement location has on how long youth remain in EFC, and expands our understanding of how county and state context shape EFC participation.

Mental Health Management Among Older Youth in Foster Care: Service Utilization and Preparedness.

PURPOSE: The aim of the study was to document mental health service use (counseling and medication) among youth in foster care, examine how prepared they feel to manage their mental health, and investigate predictors of service use and preparedness. METHODS: The study includes a representative sample of youth in California foster care at age 17 years who participated in in-person, structured interviews (n = 727). Survey measures captured youth characteristics, their mental health service use, and their level of preparedness to manage their mental health. Data from a child welfare worker survey were used to capture county-level service availability, helpfulness, and coordination. Binary and ordered logistic regression were used to predict mental health service use and preparedness. RESULTS: Youth reported high rates of mental health service use and one-fifth of the sample reported feeling less than prepared to manage their mental health. Youth who screened positive for mental disorders were less prepared than their peers to manage their mental health. Physical (odds ratio [OR] = 1.44; p < .05) and sexual abuse (OR = 2.04; p < .001) predicted past year use of counseling. Sexual abuse also predicted medication use (OR = 1.97; p < .01). Youth who identified as 100% heterosexual were less likely than non-100% heterosexual peers to use counseling (OR = .58; p < .05). The results also suggest geographic variation in use. Finally, caseworkers' perception of greater helpfulness of services in the county they worked predicted greater mental health preparedness (OR = 1.23; p < .05). CONCLUSIONS: Mental health service use remains high among youth in foster care. Youth with particular characteristics may benefit from interventions aimed at preparing them for managing their mental health in adulthood.

Kidney care in low- and middle-income countries.

Optimal kidney care requires a trained nephrology workforce, essential healthcare services, and medications. This study aimed to identify the access to these resources on a global scale using data from the multinational survey conducted by the International Society of Nephrology (ISN) (Global Kidney Health Atlas (GKHA) project), with emphasis on developing nations. For data analysis, the 125 participating countries were sorted into the 4 World Bank income groups: low income (LIC), lower-middle income (LMIC), upper-middle income (UMIC), and high income (HIC). A severe shortage of nephrologists was observed in LIC and LMIC with < 5 nephrologists per million population. Many LIC were unable to access estimated glomerular filtration rate (eGFR) and albuminuria (proteinuria) tests in primary-care levels. Acute and chronic hemodialysis was available in most countries, although acute and chronic peritoneal dialysis access was severely limited in LIC (24% and 35%, respectively). Most countries had kidney transplantation access, except for LIC (12%). HIC and UMIC funded their renal replacement therapy (RRT) and renal medications primarily through public means, whereas LMIC and LIC required private and out-of-pocket contributions. In conclusion, this study found a huge gap in the availability and access to trained nephrology workforce, tools for diagnosis and management of CKD, RRT, and funding of RRT and essential medications in LIC and LMIC.

Emancipated Foster Youth and Intimate Partner Violence: An Exploration of Risk and Protective Factors.

Due to their high rates of parental maltreatment and violence exposure, youth in the foster care system are considered particularly vulnerable to experiencing intimate partner violence (IPV) in adolescence and young adulthood. Those who have emancipated from foster care may be at a heightened risk, as they are significantly more likely to struggle in a variety of critical domains (i.e., mental health, substance use, and delinquency). This longitudinal study is the first to explore the impact of demographic, individual, family, and foster care system factors on IPV involvement for foster care alumni at age 23/24. Analyses were conducted on three waves of quantitative data from the Midwest Evaluation of the Adult Functioning of Former Foster Youth (the Midwest Study). We find that approximately 21% of the young adults in our sample were involved in some type of IPV at age 23/24, with bidirectional violence the most commonly reported form. Males were more likely than females to report IPV victimization, whereas females were more likely than males to report IPV perpetration and bidirectional violence. Young adults who reported parental IPV prior to foster care entry were more likely to be involved in bidirectionally violent partnerships than nonviolent partnerships in young adulthood, as were young adults who reported neglect by a foster caregiver and those who reported greater placement instability while in the foster care system. Anxiety at baseline increased the odds of IPV perpetration at age 23/24, and posttraumatic stress disorder (PTSD) at baseline decreased the odds of IPV perpetration at age 23/24. Understanding the characteristics and experiences that place these young adults at risk for IPV will allow for more effective and targeted prevention efforts.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

BACKGROUND: Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations. OBJECTIVE: To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada. METHODS: We analyzed electronic advice requests for nephrology services in Alberta after the system's pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis. RESULTS: The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days. CONCLUSION: These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

CONTEXTE: Les résidents des zones rurales de l'Alberta se heurtent à des obstacles importants en ce qui concerne l'accès aux soins spécialisés, ce qui entraîne des retards dans la fourniture de soins adéquats. Les systèmes électroniques de référence et de consultation sont des outils prometteurs qui peuvent faciliter un accès rapide à des soins spécialisés, en particulier pour les personnes résidant en milieu rural. OBJECTIF: Présenter notre première expérience avec le lancement d'un système de demande de consultation électronique en soins rénaux ambulatoires en Alberta, Canada. MÉTHODOLOGIE: Nous avons analysé les demandes de consultation électroniques pour des services de néphrologie en Alberta, entre octobre 2016 et décembre 2017, après le lancement pilote du système. Les données sur la pertinence des demandes de consultation à l'échelle provinciale, et selon les fournisseurs de soins primaires, ont été extraites du registre Alberta Netcare pour fins d'analyze. RÉSULTATS: Le nombre total de consultations électroniques adressées en néphrologie était de 118 (moyenne de 2 demandes/semaine), et 31 cas seulement (26,3%) ont nécessité une visite en clinique avec un néphrologue. La majorité des cas (87), soit 73,7%, a été prise en charge par des fournisseurs de soins primaires qui bénéficiaient du soutien permanent d'un néphrologue par l'entremise de l'outil électronique. Le temps de réponse moyen des néphrologues était de 5,7 ± 0,6 jour (moyenne ± SEM). CONCLUSION: Ces données préliminaires suggèrent que le program de demande de consultation électronique pourrait faciliter l'accès rapide à des soins par un néphrologue et minimiser les visites inutiles en clinique, tout en réduisant le temps de réponse. La mise en œuvre à grande échelle de ce système pourrait avoir une incidence très positive sur les résultats de santé et améliorer la rentabilité des soins en néphrologie à long terme, en particulier dans les communautés rurales de l'Alberta.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease.

BACKGROUND: As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians. OBJECTIVE: To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD. DESIGN: This is a sequential, mixed methods study that will be conducted in 3 phases. SETTING: The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]). PATIENTS: Patients suffering from CKD will be included in the study. MEASUREMENTS: We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes. METHODS: The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes. RESULTS: We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult. LIMITATIONS: Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task. CONCLUSIONS: Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents. TRIAL REGISTRATION: Not required.

CONTEXTE: Bien que le fardeau de l'insuffisance rénale chronique (IRC) ne cesse de s'alourdir, de nombreux Canadiens dispersés sur le plan géographique continuent d'avoir un accès limité à des soins spécialisés puisque ceux-ci sont davantage concentrés dans les grandes zones urbaines. Ainsi, dans les régions rurales/éloignées du Canada, de nombreux patients atteints d'IRC ne reçoivent pas les soins appropriés et subissent les conséquences néfastes des pathologies associées à leur état de santé. Il est donc essentiel de développer des mécanismes alternatifs de prestation de soins pour s'assurer que tous les Canadiens ont accès à des soins optimaux. OBJECTIF: Évaluer la faisabilité et l'efficacité d'un système de consultation électronique (eConsult) facilitant les interactions entre les spécialistes et les fournisseurs de soins primaires (FSP) dans le but d'améliorer l'accès des patients atteints d'IRC à des soins spécialisés. TYPE D'ÉTUDE: Une étude séquentielle en trois phases reposant sur des méthodes mixtes. CADRE: L'étude sera menée à la grandeur de l'Alberta avec le soutien financier du Alberta Kidney Care (anciennement Northern/Southern Alberta Renal Program [NARP/SARP]). SUJETS: Des patients atteints d'IRC participeront à l'étude. MESURES: Nous étudierons les facteurs qui entravent ou qui facilitent la mise en œuvre et l'adoption d'un système d'eConsult visant à améliorer l'accès des Albertains atteints d'IRT à des soins spécialisés, particulièrement ceux qui résident en région rurale/éloignée. Nous évaluerons les impacts de l'eConsult (meilleur accès à des soins spécialisés, réduction des disparités) et la faisabilité de son implantation à l'échelle de la province. Enfin, nous comparerons l'accès aux soins spécialisés, leur qualité et l'incidence des pathologies associées selon que l'eConsult est employée seule ou avec facilitation de la pratique. MÉTHODOLOGIE: L'étude se déroulera en trois étapes. Par l'entremise de groupes de discussion et d'interviews semi-structurées, la phase 1 évaluera la perception des différents intervenants (FSP, néphrologues, patients, décideurs et autres fournisseurs de soins) quant à l'amélioration de la prestation et de la qualité des soins spécialisés, et des résultats de santé. La phase 2 sondera l'avis de médecins de famille sélectionnés sur les problèmes logistiques et les principaux facteurs affectant l'implantation du système d'eConsult. La phase 3 fournira de la formation continue aux cliniques albertaines, notamment en facilitation de la pratique, et comparera les effets de l'eConsult avec facilitation de la pratique et de l'eConsult employée seule sur l'accès aux soins spécialisés, la qualité des soins et les pathologies associées. RÉSULTATS: Nous questionnerons les différents intervenants sur les éventuels obstacles et facilitateurs d'une nouvelle stratégie d'eConsult et d'aide à la prise de décision, en nous concentrant sur les éléments les plus importants pour la conception d'une intervention réalisable et applicable. Nous élaborerons le modèle d'eConsult, le mettrons à l'essai et évaluerons son incidence sur l'amélioration de l'accès aux soins spécialisés en néphrologie et sur la faisabilité de difficultés de prodiguer des soins optimaux aux patients atteints d'IRC des zones rurales, éloignées et mal desservies de l'Alberta, particulièrement en ce qui concerne l'aiguillage rapide et la gestion de la maladie. Les avantages économiques de l'eConsult seront également abordés au cours de cette phase. LIMITES: L'absence d'internet haute vitesse dans de nombreuses régions rurales et éloignées de l'Alberta pourrait faire en sorte qu'il soit plus rapide d'envoyer la demande par télécopieur que de la remplir en ligne. Le personnel paramédical (coordonnateurs de l'aiguillage, personnel administratif) doit être formé sur le système eConsult et plusieurs centers éloignés n'ont pas suffisamment de personnel pour s'en occuper comme tâche supplémentaire. CONCLUSION: L'implantation d'un système d'eConsult en contexte d'IRC pourrait améliorer les schémas d'aiguillage, l'accès aux soins spécialisés, leur qualité et les résultats des patients, de même que réduire les coûts de santé. Les résultats de cette étude guideront l'optimisation des soins en IRC dans les régions rurales/éloignées et faciliteront les futurs partenariats avec les décideurs et les programs provinciaux de néphrologie en Alberta, afin d'assurer une santé rénale optimale à tous les résidents.

Examining the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in Uganda.

In this study, we examined the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in HIV-impacted communities in Uganda. We analyzed data from a cluster randomized experimental study for orphaned adolescents aged 11-17 years. Participants were randomly assigned to either the control condition, which received bolstered standard of care (BSOC) services, or the treatment condition, which received BSOC services plus an economic-strengthening intervention. We conducted binary logistic regression analyses to examine the effect of the intervention on participants' nonkin support networks. Results indicated that the existing social support networks for orphaned adolescents are small, limited, and usually comprised individuals with similar socioeconomic situations and challenges. Because orphaned adolescents are socially isolated and the threshold for nonkin supportive services is very low, the BSOC services provided to the control condition appeared to be instrumental in their survival and well-being. Availability of personal savings was associated with higher odds of identifying at least one supportive nonkin tie. The extended family system is still the primary and major source of social support to orphaned children in HIV-affected communities. In the absence of public safety nets, building social assets, over and above offering economic opportunities to extended families supporting orphaned children, is critical.

Ruling out Pulmonary Embolism in Patients with High Pretest Probability.

INTRODUCTION: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients. METHODS: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%. RESULTS: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells >6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%-40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up. CONCLUSION: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.

Adverse Childhood Experiences and Young Adult Health Outcomes Among Youth Aging Out of Foster Care.

OBJECTIVE: Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has shown a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. In this study we used person-centered latent class analysis methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories among this high-risk population. METHODS: Data are from longitudinal research that followed transition-age YFC from age 17 to 26 (N = 732). Using 3 subgroups previously identified by their ACEs histories-complex, environmental, and lower adversity groups-we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood. RESULTS: In contrast to previous research that showed that the environmental group was at the highest risk of criminalbehavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this study, the complex adversity group had the highest risk. CONCLUSIONS: This study shows that there are subgroups of YFC, which each have a distinct profile of risk in young adulthood, with the complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult health care, and continuity of care for adolescents and young adults in foster care to offset these trajectories.

Characteristics of foster care history as risk factors for psychiatric disorders among youth in care.

This study evaluates foster care history characteristics as risk factors for psychopathology. We examine characteristics of youths' foster care histories separately and as a gestalt (i.e., identification of latent classes). Six mental health disorders and lifetime suicide attempt were assessed via in-person interviews with a representative sample of older adolescents in California foster care (n = 706). Information on respondents' foster care histories were obtained from state administrative data. Half of the sample (47.3%) screened positive for a psychiatric disorder and 1/4 (25.2%) had attempted suicide. When assessed individually, placement instability predicted posttraumatic stress disorder (PTSD), alcohol and substance use problems, and suicide attempt. Primary placement type and maltreatment type were also associated with 1 or more psychiatric disorders. When foster care characteristics were considered in concert, 6 latent classes were identified: veterans, returners, treated stayers, midrangers, late stayers, and disquieted drifters. Three latent classes (returners, late stayers, and disquieted drifters) were at increased risk of psychiatric problems relative to 1 or more of the other latent classes. Both separate foster care characteristics and the gestalt of youths' foster care histories identified risks of psychiatric problems. Results from these analyses can inform the development of risk assessment tools. (PsycINFO Database Record

Global nephrology workforce: gaps and opportunities toward a sustainable kidney care system.

The health workforce is the cornerstone of any health care system. An adequately trained and sufficiently staffed workforce is essential to reach universal health coverage. In particular, a nephrology workforce is critical to meet the growing worldwide burden of kidney disease. Despite some attempts, the global nephrology workforce and training capacity remains widely unknown. This multinational cross-sectional survey was part of the Global Kidney Health Atlas project, a new initiative administered by the International Society of Nephrology (ISN). The objective of this study was to address the existing global nephrology workforce and training capacity. The questionnaire was administered online, and all data were analyzed and presented by ISN regions and World Bank country classification. Overall, 125 United Nations member states responded to the entire survey, with 121 countries responding to survey questions pertaining to the nephrology workforce. The global nephrologist density was 8.83 per million population (PMP); high-income countries reported a nephrologist density of 28.52 PMP compared with 0.31 PMP in low-income countries. Similarly, the global nephrologist trainee density was 1.87 PMP; high-income countries reported a 30 times greater nephrology trainee density than low-income countries (6.03 PMP vs. 0.18 PMP). Countries reported a shortage in all care providers in nephrology. A nephrology training program existed in 79% of countries, ranging from 97% in high-income countries to 41% in low-income countries. In countries with a training program, the majority (86%) of programs were 2 to 4 years, and the most common training structure (56%) was following general internal medicine. We found significant variation in the global density of nephrologists and nephrology trainees and shortages in all care providers in nephrology; the gap was more prominent in low-income countries, particularly in African and South Asian ISN regions. These findings point to significant gaps in the current nephrology workforce and opportunities for countries and regions to develop and maintain a sustainable workforce.

Comparison of acute and convalescent biomarkers of inflammation in patients with acute pulmonary embolism treated with systemic fibrinolysis vs. placebo.

: Previous studies have associated biomarkers indicative of acute inflammation with pulmonary embolism, which may amplify coagulation, inhibit fibrinolysis and increase risk of venous thromboembolism (VTE) recurrence. The aim of this study was to measure inflammatory and hemostatic biomarkers in acute submassive pulmonary embolism at diagnosis and 3-month follow-up and to test the impact of treatment with fibrinolysis. Secondary analysis of a multicenter, double-blinded, randomized controlled trial including patients with submassive pulmonary embolism. Blood samples were obtained within 24 h of diagnosis and prior to bolus-dose tenecteplase (TNK) or placebo; all patients received standard anticoagulation and blood was redrawn 3 months later. Plasma concentrations of inflammatory [Interleukin 6 (IL-6), C-reactive protein (CRP), myeloperoxidase (MPO)] and hemostatic [plasminogen activator inhibitor-1 (PAI-1), fibrinogen, thrombin-activatable fibrinolysis inhibitor and D-dimer] biomarkers were quantified. The median values of the biomarkers of inflammation (IL-6, CRP, MPO) were all significantly decreased at 3-month follow-up, ranging from a 60 to 91% reduction over this time period. Concentrations of PAI-1 and fibrinogen did not change significantly. D-dimer concentration at 3-month follow-up was lower in patients treated with fibrinolysis vs. placebo and appeared to have a trend toward significance (placebo 310 vs. TNK 220 ng/ml, P = 0.051). Acute pulmonary embolism causes marked but transient inflammation, as demonstrated by the significant elevation in the inflammatory biomarkers at diagnosis, followed by their reduction in more than 80% of patients at 3-month follow-up.

Acogimiento residencial terapéutico para niños y adolescentes: una declaración de consenso del Grupo de Trabajo Internacional sobre Acogimiento Residencial Terapéutico / Therapeutic Residential Care for Children and Youth: A Consensus Statement of the International Work Group on Therapeutic Residential Care

En muchos países desarrollados a lo largo del mundo las intervenciones en acogimiento residencial para niños y adolescentes se encuentran en un momento de creciente debate. Ante esta situación, se organizó una cumbre internacional en Inglaterra (primavera de 2016) con expertos de 13 países para reflexionar sobre el acogimiento residencial terapéutico (ART). Se partió de la siguiente definición de ART: "el acogimiento residencial terapéutico implica el uso planificado de un ambiente de convivencia multidimensional, construido a propósito, diseñado para desarrollar o proveer tratamiento, educación, socialización, apoyo y protección a niños y jóvenes con necesidades reconocidas de salud mental o conductuales, en cooperación con sus familias y la colaboración de un amplio espectro recursos comunitarios formales e informales». La reunión se caracterizó por el intercambio de información y evidencias y la preparación de una agenda internacional de investigación. Además, se discutieron las bases para una declaración de consenso. Esta declaración, originalmente publicada en inglés y ahora reproducida en español, comprende, entre otras cuestiones, cinco principios básicos de acogimiento que de acuerdo con el grupo de trabajo en acogimiento residencial terapéutico deben guiar el acogimiento residencial de jóvenes que se preste en todo momento (AU)

In many developed countries around the world residential care interventions for children and adolescents have come under increasing scrutiny. Against this background an international summit was organised in England (spring 2016) with experts from 13 countries to reflect on therapeutic residential care (TRC). The following working definition of TRC was leading: «Therapeutic residential care involves the planful use of a purposefully constructed, multi-dimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families and in collaboration with a full spectrum of community based formal and informal helping resources». The meeting was characterised by exchange of information and evidence, and by preparing an international research agenda. In addition, the outlines of a consensus statement on TRC were discussed. This statement, originally published in English and now reproduced in a Spanish translation, comprises inter alia five basic principles of care that according to the Work Group on Therapeutic Residental Care should be guiding for residential youth care provided at any time (AU)

Quality Assurance Audit of Technique Failure and 90-Day Mortality after Program Discharge in a Canadian Home Hemodialysis Program.

BACKGROUND AND OBJECTIVES: Little is known about patients exiting home hemodialysis. We sought to characterize the reasons, clinical characteristics, and pre-exit health care team interactions of patients on home hemodialysis who died or underwent modality conversion (negative disposition) compared with prevalent patients and those who were transplanted (positive disposition). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted an audit of all consecutive patients incident to home hemodialysis from January of 2010 to December of 2014 as part of ongoing quality assurance. Records were reviewed for the 6 months before exit, and vital statistics were assessed up to 90 days postexit. RESULTS: Ninety-four patients completed training; 25 (27%) received a transplant, 11 (12%) died, and 23 (25%) were transferred to in-center hemodialysis. Compared with the positive disposition group, patients in the negative disposition group had a longer mean dialysis vintage (3.15 [SD=4.98] versus 1.06 [SD=1.16] years; P=0.003) and were performing conventional versus a more intensive hemodialysis prescription (23 of 34 versus 23 of 60; P<0.01). In the 6 months before exit, the negative disposition group had significantly more in-center respite dialysis sessions, had more and longer hospitalizations, and required more on-call care team support in terms of phone calls and drop-in visits (each P<0.05). The most common reason for modality conversion was medical instability in 15 of 23 (65%) followed by caregiver or care partner burnout in three of 23 (13%) each. The 90-day mortality among patients undergoing modality conversion was 26%. CONCLUSIONS: Over a 6-year period, approximately one third of patients exited the program due to death or modality conversion. Patients who die or transfer to another modality have significantly higher health care resource utilization (e.g., hospitalization, respite treatments, nursing time, etc.).

[Therapeutic Residential Care for Children and Youth: A Consensus Statement of the International Work Group on Therapeutic Residential Care].

Therapeutic Residential Care for Children and Youth: A Consensus Statement of the International Work Group on Therapeutic Residential Care. In many developed countries around the world residential care interventions for children and adolescents have come under increasing scrutiny. Against this background an international summit was organised in England (spring 2016) with experts from 13 countries to reflect on therapeutic residential care (TRC). The following working definition of TRC was leading: “Therapeutic residential care involves the planful use of a purposefully constructed, multi-dimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families and in collaboration with a full spectrum of community based formal and informal helping resources”. The meeting was characterised by exchange of information and evidence, and by preparing an international research agenda. In addition, the outlines of a consensus statement on TRC were discussed. This statement, originally published in English and now reproduced in a Spanish translation, comprises inter alia five basic principles of care that according to the Work Group on Therapeutic Residental Care should be guiding for residential youth care provided at any time.