Primary Total Knee and Total Hip Arthroplasty in the Rural Patient.

Rural patients have poorer health indicators, including higher risk of developing osteoarthritis. The objective of this study is to compare rural patients undergoing primary total joint arthroplasty (TJA) at rural hospitals with those undergoing primary TJA at urban hospitals with regards to demographics, comorbidities, and complications and to determine the preferred location of care for rural patients. Data from the Healthcare Cost and Utilization Project National Inpatient Sample between 2016 and 2018 were analyzed. Demographics, comorbidities, inpatient complications, hospital length of stay, inpatient mortality, and discharge disposition were compared between rural patients who underwent TJA at rural hospitals and urban hospitals. Rural patients undergoing primary TJA in rural hospitals were more likely to be women, to be treated in the South, to have Medicaid payer status, to have dementia, diabetes mellitus, lung disease, and postoperative pulmonary complications, and to have a longer hospital length of stay. Those patients were also less likely to have baseline obesity, heart disease, kidney disease, liver disease, cancer, postoperative infection, and cardiovascular complications, and were less likely to be discharged home. Rural patients undergoing primary TJA tend to pursue surgery in their rural hospital when their comorbidity profile is manageable. These patients get their surgery performed in an urban setting when they have the means for travel and cost, and when their comorbidity profile is more complicated, requiring more specialized care, Rural patients are choosing to undergo their primary TJA in urban hospitals as opposed to their local rural hospitals. (Journal of Surgical Orthopaedic Advances 33(2):061-067, 2024).

Impact of the SARS-CoV-2 pandemic on acute coronary syndrome patients admitted to an urban academic hospital in Soweto, South Africa.

Introduction: recent worldwide data has shown a concerning decline in the number of acute coronary syndrome (ACS) related admissions and percutaneous coronary intervention (PCI) procedures during the coronavirus disease 2019 (COVID-19) pandemic. We suspected a similar trend at Chris Hani Baragwanath Hospital (CHBAH). Methods: a retrospective descriptive study was conducted to evaluate and compare all ACS-related admissions to the cardiac care unit (CCU) at CHBAH in the pre-COVID-19 (November 2019 to March 2020) and during COVID-19 periods (April 2020 to August 2020). Results: the study comprised 182 patients with a mean age of 57.9 ±10.9 years (22.5% females). Of these, 108 (59.32%) patients were admitted in the pre-COVID-19 period and 74 (40.66%) during COVID-19 (p=0.0109). During the pre-COVID-19 period, 42.9% of patients had ST-segment-elevation myocardial infarction (STEMI), 39.2% with non-ST-segment -elevation myocardial infarction (NSTEMI) and unstable angina (UA) was noted in 18.52%. In contrast, STEMI was noted in 50%, NSTEMI in 43.24% and UA in 6.76% of patients during the COVID-19 period. A statistically significant difference in STEMI and NSTEMI-related admissions was not noted, however, there was a greater number of admissions for UA during the pre-COVID-19 period (18.52% vs 6.76%, P =0.013). Only a third of the patients with STEMI received thrombolysis during the pre-and COVID-19 periods (30.4% vs 37.8%, P=0.47). No difference in the number of PCI procedures was noted between the pre-and during the COVID-19 periods (78.7% vs 72.9%, P=0.37). Conclusion: there was a difference in overall ACS admissions to the CCU between pre-and during COVID-19 periods, however no difference between STEMI and NSTEMI in both periods. A higher number of UA admissions was noted during the pre-COVID-19 period. During both periods, the use of thrombolysis was low for STEMI and no difference in PCI was noted.

Risk-reducing salpingo-oophorectomy among diverse patients with BRCA mutations at an urban public hospital: a mixed methods study.

OBJECTIVES: To assess the association of socioeconomic demographics with recommendation for and uptake of risk-reducing bilateral salpingo-oophorectomy (rrBSO) in patients with BRCA1 and BRCA2 (BRCA1/2) mutations. DESIGN: Retrospective cohort, semistructured qualitative interviews. SETTING AND PARTICIPANTS: BRCA1/2 mutation carriers at an urban, public hospital with a racially and socioeconomically diverse population. INTERVENTION: None. PRIMARY AND SECONDARY OUTCOMES: The primary outcomes were rate of rrBSO recommendation and completion. Secondary outcomes were sociodemographic variables associated with rrBSO completion. RESULTS: The cohort included 167 patients with BRCA1/2 mutations of whom 39% identified as black (n=65), 35% white (n=59) and 19% Hispanic (n=32). Over 95% (n=159) received the recommendation for age-appropriate rrBSO, and 52% (n=87) underwent rrBSO. Women who completed rrBSO were older in univariable analysis (p=0.05), but not in multivariable analysis. Completion of rrBSO was associated with residence in zip codes with lower unemployment and documented recommendation for rrBSO (p<0.05). All subjects who still received care in the health system (n=79) were invited to complete interviews regarding rrBSO decision-making, but only four completed surveys for a response rate of 5.1%. Themes that emerged included menopause, emotional impact and familial support. CONCLUSIONS: In this understudied population, genetic counselling and surrogates of financial health were associated with rrBSO uptake, highlighting genetics referrals and addressing social determinants of health as opportunities to improve cancer prevention and reduce health inequities. Our study demonstrates a need for more culturally centred recruiting methods for qualitative research in marginalised communities to ensure adequate representation in the literature regarding rrBSO.

Therapeutic Drug Monitoring Characteristics in a City Hospital for a Year.

BACKGROUND: Therapeutic drug monitoring (TDM) involves the measurement of drug concentrations in serum, plasma, whole blood, or other biologic fluids. This study focused on evaluating the TDM requests of a city hospital over a period of one year, retrospectively. METHODS: The study retrospectively analyzed TDM requests for carbamazepine, cyclosporine-A, digoxin (DIGOX), lithium (LITH), methotrexate (MTX), phenitoin, tacrolimus, and valproic acid (VALP) from June 1, 2022, to June 1, 2023. Parameters such as the age and the gender of patients, the requesting departments, the measurement results, and the turnaround time (TAT) were assessed. Drug concentrations below the reference values were classified as subtherapeutic, whereas concentrations above the reference values were considered supratherapeutic. RESULTS: In total, 10,913 drug concentration measurement records were analyzed. The gender distribution was 51.6% male and 48.4% female. Pediatric samples comprised 6.2% and elderly samples 8.6% of the total. Notably, DIGOX, LITH, and VALP levels showed a significant correlation with age (p = < 0.0001, p = < 0.0001, and p = 0.0002, respectively). TAT was maintained at 360 minutes (6 hours) for all tests. CONCLUSIONS: The study found significant correlations between age and DIGOX, LITH, and VALP levels. TDM plays a critical role in the elderly population, necessitating careful management of these drugs.

Evaluation of geographic variations in appendicectomy outcomes within Western Australia assessing the impact of surgical wait times and rate of negative appendicectomies in both urban and rural locations statewide.

PURPOSE: Surgery wait times after diagnosis of appendicitis are an important factor influencing the success of a patient's treatment. The proposed study will be a quantitative multicenter retrospective cohort design with the primary aim of assessing the difference between appendicectomy wait times between rural and urban hospitals in Western Australia and the effect of this on operative outcomes. Selected outcome measures will be examined by time from initial presentation at an emergency department to the patient being diagnosed and then time of diagnosis to surgery being performed. The secondary aim is to compare rates of negative appendicectomies between hospitals. METHODS: Appendicectomy patients will be identified from operating room register by medical student data collectors; then, each respective hospital's emergency room data collection will subsequently be accessed to complete case report forms based on demographics and clinical findings, pre-operative investigations, and management and follow-up. Case report forms with > 95% completeness will be accepted for pooled analysis. The expected duration of retrospective data collection will be 8 months. This study RGS6483 has received HREC approval by the Royal Perth Hospital HREC Ethics Committee, with a waiver of consent obtained and the HREC was notified of amendments to the protocol made on April 21, 2024. Dissemination of results. Data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. No patient-identifiable data will be entered into the system. Results will subsequently be shared via scientific journal publication and presentation at relevant meetings.

Assessing Fall Mortality by Field-Relevant Categories at an Urban Level I Trauma Center.

INTRODUCTION: Little research has focused on assessing the mortality for fall height based on field-relevant categories like falls from greater than standing (FFGS), falls from standing (FFS), and falls from less than standing. METHODS: This retrospective observational study included patients evaluated for a fall incident at an urban Level I Trauma Center or included in Medical Examiner's log from January 1, 2015, to June 31, 2017. Descriptive statistics characterized the sample based on demographic variables such as age, race, sex, and insurance type, as well as injury characteristics like relative fall height, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), traumatic brain injury, intensive care unit length of stay, and mortality. Bivariate analysis included Chi-square tests for categorical variables and Student t-tests for continuous variables. Subsequent multiple logistic regression modeled significant variables from bivariate analyses, including age, race, insurance status, fall height, ISS, and GCS. RESULTS: When adjusting for sex, age, race, insurance, ISS, and GCS, adults ≥65 who FFS had 1.93 times the odds of mortality than those who FFGS. However, those <65 who FFGS had 3.12 times the odds of mortality than those who FFS. Additionally, commercial insurance was not protective across age groups. CONCLUSIONS: The mortality for FFS may be higher than FFGS under certain circumstances, particularly among those ≥65 y. Therefore, prehospital collection should include accurate assessment of fall height and surface (i.e., water, concrete). Lastly, commercial insurance was likely a proxy for industrial falls, accounting for the surprising lack of protection against mortality.

Hereditary Cancer Screening and Outcomes at an Urban Safety-Net Hospital.

PURPOSE: Patients with hereditary cancer syndromes (HCS) have a high lifetime risk of developing cancer. Historically underserved populations have lower rates of genetic evaluation. We sought to characterize demographic factors that are associated with undergoing HCS evaluation in an urban safety-net patient population. METHODS: All patients who met inclusion criteria for this study from 2016 to 2021 at an urban safety-net hospital were included in this analysis. Inclusion criteria were pathologically confirmed breast, ovarian/fallopian tube, colon, pancreatic, and prostate cancers. Patients also qualified for hereditary breast and ovarian cancers or Lynch syndrome on the basis of National Comprehensive Cancer Network guidelines. Institutional review board approval was obtained. Demographic and oncologic data were collected through retrospective chart review. Univariable and multivariable logistic regression models were constructed. RESULTS: Of the 637 patients included, 40% underwent genetic testing. Variables associated with receiving genetic testing on univariable analysis included patients living at the time of data collection, female sex, Latinx ethnicity, Spanish language, family history of cancer, and referral for genetic testing. Patients identifying as Black, having Medicare, having pancreatic or prostate cancer, having stage IV disease, having Eastern Cooperative Oncology Group (ECOG) prognostic score ≥1, having medium or high Charlson comorbidity index, with current or previous cigarette use, and with previous alcohol use were negatively associated with testing. On multivariable modeling, family history of cancer was positively associated with testing. Patients identifying as Black, having colon or prostate cancer, and having ECOG score of 2 had significantly lower association with genetic testing. CONCLUSION: Uptake of HCS was lower in patients identifying as Black, those with colon or prostate cancer, and those with an ECOG score of 2. Efforts to increase HCS testing in these patients will be important to advance equitable cancer care.

Comparative analysis of patient demographics, perioperative outcomes, and adverse events after lumbar spinal fusion between urban and rural hospitals: an analysis of the National Inpatient Sample (NIS) database.

OBJECTIVE: Rural location of a patient's primary residence has been associated with worse clinical and surgical outcomes due to limited resource availability in these parts of the US. However, there is a paucity of literature investigating the effect that a rural hospital location may have on these outcomes specific to lumbar spine fusions. METHODS: Using the National Inpatient Sample (NIS) database, we identified all patients who underwent primary lumbar spinal fusion in the years between 2009 and 2020. Patients were separated according to whether the operative hospital was considered rural or urban. Univariable and multivariable regression models were used for data analysis. RESULTS: Of 2,863,816 patients identified, 120,298 (4.2 %) had their operation at a rural hospital, with the remaining in an urban hospital. Patients in the urban cohort were younger (P < .001), more likely to have private insurance (39.81 % vs 31.95 %, P < .001), and fewer of them were in the first (22.52 % vs 43.00 %, P < .001) and second (25.96 % vs 38.90 %, P < .001) quartiles of median household income compared to the rural cohort. The urban cohort had significantly increased rates of respiratory (4.49 % vs 3.37 %), urinary (5.25 % vs 4.15 %), infectious (0.49 % vs 0.32 %), venous thrombotic (0.57 % vs 0.24 %, P < .001), and neurological (0.79 % vs 0.36 %) (all P < .001) perioperative complications. On multivariable analysis, the urban cohort had significantly increased odds of the same perioperative complications: respiratory (odds ratio[OR] = 1.48; 95 % confidence interval [CI], 1.26-1.74), urinary (OR = 1.34; 95 %CI, 1.20-1.50), infection (OR = 1.63; 95 %CI, 1.23-2.17), venous thrombotic (OR = 1.79; 95 %CI, 1.32-2.41), neurological injury (OR = 1.92; 95 %CI, 1.46-2.53), and localized infection (OR = 1.65; 95 %CI, 1.25-2.17) (all P < .001). CONCLUSIONS: Patients undergoing lumbar fusions experience significantly different outcomes based on the rural or urban location of the operative hospital.

A Quality Improvement Project to Increase Infection Control Compliance Among Endoscopy Staff at a Large Urban Medical Center.

Although nurses and other healthcare professionals play a key role in preventing hospital-associated infections, studies show that infection control compliance rates have remained low. The purpose of this quality improvement project was to increase infection control compliance of hand hygiene and procedure room disinfection among endoscopy staff at a large urban medical center in Cincinnati, Ohio. This quality improvement project provided an education session on current evidence-based infection control guidelines to 20 participants, including registered nurses and technicians within the endoscopy department. Direct observational audits were conducted 4 weeks before and 4 weeks after the education session, measuring compliance with hand sanitizer, soap and water, and procedure room disinfection, over a period of 150 days. The project goals were met, as hand sanitizer compliance improved by 12%-83%; overall soap and water compliance improved by 20%-75%; and endoscopy procedure room disinfection compliance improved by 14%-92%.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients. METHODS: We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation. RESULTS: The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults. CONCLUSIONS: Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Health service providers experience of psycho-emotional violence and associated factors among urban hospitals in Eastern Ethiopia.

Background: Psycho-emotional violence, a type of workplace violence targeting healthcare workers, varies across countries, occasions, and professions in the healthcare sector. Unfortunately, there is a scarcity of comprehensive studies focusing on violence against healthcare workers in Ethiopia, which may also encompass psycho-gender-based emotional violence against healthcare workers. Therefore, there is a compelling need for in-depth research to address this gap and develop effective strategies to mitigate psycho-emotional violence in the healthcare sector in Ethiopia, especially in the eastern region. Hence, we aimed to identify the prevalence of and factors associated with workplace psycho-emotional violence against healthcare providers in eastern Ethiopia. Methods: This institution-based cross-sectional study was conducted among 744 health professionals working in urban public hospitals in eastern Ethiopia. Multistage stratified random sampling was used, and data were collected using a standardized structured tool adopted from the WHO workplace violence assessment tool. Binary and multivariable logistic regression analyses were employed to identify factors associated with psycho-emotional workplace violence. Adjusted odds ratio (OR) with 95% confidence interval (CI) was reported, and a p-value of 0.05 was used as the cut-off point to declare significance. Results: Workplace psycho-emotional violence was reported by 57.39% of the healthcare workers. The absence of guidelines for gender-based abuse [AOR = 35.62, 95% CI:17.47, 72.64], presence of measures that improve surroundings (class lighting and privacy) [AOR = 0.58, 95% CI: 0.35, 0.98], training on workplace violence coping mechanism [AOR = 0.16, 95%CI: 0.26, 0.98], spending more than 50% of their time with HIV/AIDS patients [AOR = 1.96, 95%CI:1.05, 3.72], and spending more than 50% of their time with psychiatric patients [AOR = 1.92, 95%CI:1.08, 3.43] were factors significantly associated with workplace violence against health professionals. Conclusion: The prevalence of workplace psycho-emotional violence against health professionals in eastern Ethiopia was relatively high. Improving the working environment decreases the chance of workplace violence; however, there is a lack of guidelines for gender-based violence, the absence of training on coping mechanisms, and spending more time with psychiatric and HIV/AIDS patients' increases workplace violence. We recommend that health institutions develop gender abuse mitigation guidelines and provide training on coping mechanisms.

Rural Hospitals Experienced More Patient Volume Variability Than Urban Hospitals During The COVID-19 Pandemic, 2020-21.

Fluctuations in patient volume during the COVID-19 pandemic may have been particularly concerning for rural hospitals. We examined hospital discharge data from the Healthcare Cost and Utilization Project State Inpatient Databases to compare data from the COVID-19 pandemic period (March 8, 2020-December 31, 2021) with data from the prepandemic period (January 1, 2017-March 7, 2020). Changes in average daily medical volume at rural hospitals showed a dose-response relationship with community COVID-19 burden, ranging from a 13.2 percent decrease in patient volume in periods of low transmission to a 16.5 percent increase in volume in periods of high transmission. Overall, about 35 percent of rural hospitals experienced fluctuations exceeding 20 percent (in either direction) in average daily total volume, in contrast to only 13 percent of urban hospitals experiencing similar magnitudes of changes. Rural hospitals with a large change in average daily volume were more likely to be smaller, government-owned, and critical access hospitals and to have significantly lower operating margins. Our findings suggest that rural hospitals may have been more vulnerable operationally and financially to volume shifts during the pandemic, which warrants attention because of the potential impact on these hospitals' long-term sustainability.

Analysis of candidemia cases in a city hospital during the COVID-19 pandemic.

OBJECTIVE: The frequency and mortality of candidemia remain important. Non-albicans Candida species such as C. auris are increasing. PATIENTS AND METHODS: A retrospective review of adult patients diagnosed with bloodstream infection due to Candida species in the 17 months between July 1, 2020, and December 1, 2021, was performed. Yeast colonies grown in culture were identified by matrix-assisted laser desorption/ionization time-of-flight. Antifungal susceptibility tests of Candida strains were performed with Sensititre YeastOne (TREK Diagnostic Systems Inc., Westlake, Ohio) kits, and minimum inhibitory concentration values were evaluated according to the Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints. RESULTS: In total, 217 patients (mean age 64.9±15.7 years) were included. C. albicans was the most common fungus (detected in 82 patients; 37.8%), followed by C. parapsilosis (17.1%), C. glabrata (15.2%), C. tropicalis (15.2%), and C. auris (9%). Candidemia developed in 175 (81.4%) of the cases during their intensive care unit stay. Fluconazole (41.0%) and caspofungin (36.4%) were the two most frequently used antifungal agents in antifungal therapy. There were 114 (52.3%) deaths in the study group. Mortality rates were found to be lower in patients infected with C. parapsilosis or C. auris. Age and previous COVID-19 infection were other important risk factors. When the 217 Candida spp. were examined, resistance and intermediate susceptibility results were higher when EUCAST criteria were used. While the two methods were found to be fully compatible only for fluconazole, a partial agreement was also observed for voriconazole. CONCLUSIONS: As our study observed, the COVID-19 pandemic brought increasing numbers of immunosuppressed patients, widespread use of antibacterials, and central venous catheters, increasing the frequency and mortality of candidemia cases. All health institutions should be prepared for the diagnosis and treatment of candidemia. In addition, C. auris, the frequency of which has increased in recent years, is a new factor that should be considered in candidemia cases.

Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center.

PURPOSE: To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED. METHODS: We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%. RESULTS: The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001). CONCLUSION: The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.

National Hospital Care Survey Demonstration Projects: Examination of Maternal Health Outcomes by Housing Assistance Status.

Objectives-Objective-This report demonstrates the use of linked National Hospital Care Survey (NHCS) and U.S. Department of Housing and Urban Development (HUD) administrative data to examine demographic characteristics and maternal health outcomes among both patients who received and did not receive housing assistance. Methods-Administrative claims data and electronic health records data from the 2016 NHCS were linked to 2015-2017 HUD administrative data using patient identifiers. HUD administrative data for Housing Choice Voucher, Public Housing, and Multifamily housing program participation were used to identify patients who received housing assistance before, during, or after their delivery hospitalization. Exploratory analyses were conducted for patients who had a delivery hospitalization in 2016 and were eligible for linkage to HUD administrative data. Demographic characteristics and maternal health outcomes were compared by housing assistance status. The linked NHCS-HUD data are unweighted and not nationally representative. Results-In the 2016 NHCS, 146,672 patients had a delivery hospitalization and were eligible for linkage to 2015-2017 HUD administrative data (95.6% had a live birth, 1.0% had a stillbirth, and 3.4% were unspecified). Among this study population, 9,559 patients (6.5%) received housing assistance from 2015 to 2017. Among those who received housing assistance, 66.5% visited large metropolitan hospitals, 71.8% were insured by Medicaid, and 3.0% experienced severe maternal morbidity. Among patients who did not receive housing assistance, 74.0% visited large metropolitan hospitals, 35.6% were insured by Medicaid, and 1.9% experienced severe maternal morbidity. Nearly two-thirds of patients who received housing assistance from 2015 to 2017 were receiving housing assistance at the time of their delivery hospitalization (63.6%). Conclusion-Although these findings are not nationally representative, this report illustrates how linked NHCS-HUD data may provide insight into maternal health outcomes of patients who received housing assistance compared with those who did not.

The First Nations experience of accessing rheumatology services in a metropolitan hospital: A qualitative study.

OBJECTIVE: First Nations Australians experience a higher burden and severity of Rheumatic Disease with poorer outcomes than the general population. Despite a widely acknowledged need to improve health outcomes, there has been minimal research assessing existing models of care from a First Nations perspective in Australia. The objective of this study was to describe First Nations experiences and barriers and enablers to accessing a hospital-based adult Rheumatology service in Sydney. METHODS: A qualitative study using semi-structured interviews was undertaken. Patients who self-identified as First Nations attending the Prince of Wales Hospital Rheumatology Clinic in 2021 were invited to participate. Interviews were conducted face-to-face or by telephone using culturally-appropriate Yarning methods with an Aboriginal Health Worker (AHW) at the request of participants. Thematic analysis was done in consultation with an Aboriginal Reference Group (ARG). RESULTS: Four categories, which encapsulated 11 themes were identified. Participants reported barriers to care such as logistics of the referral process, not feeling culturally safe because of uncomfortable clinic environments and health worker behaviours, inadequate cultural support and community perceptions of the specialty. Enabling factors included family member involvement, AHW support and telehealth consultation. CONCLUSION: The current model of care perpetuates access challenges for First Nations Australians within rheumatology. Barriers to care include the delayed referral process, limited cultural responsivity in the clinic environment and poor cross-cultural communication. There is a need for models of care that are co-designed with First Nations Peoples to address these barriers. PATIENT AND PUBLIC CONTRIBUTION: Participants were First Nations Australians with lived experience attending the rheumatology clinic. All interviewees were offered the opportunity to review their transcripts to ensure trustworthiness of the data. Preliminary thematic analysis was conducted in partnership with the AHW who has over 20 years experience. Following preliminary coding, a list of themes were presented to the ARG for iterative discussion and refinement. The ARG provided community representation and ensured that First Nations voices were privileged in the analysis. It's intended that the findings of this study will support the upcoming co-design of a First Nations health service for Rheumatology patients.

Anesthetic approach to trauma patients in the city hospital after the 2023 Maras earthquake.

BACKGROUND: The February 6, 2023, Kahramanmaras earthquake caused significant destruction across our country. More than 50,000 people lost their lives, thousands were injured, and health facilities were damaged. Victims were transferred to hospitals in other provinces for treatment. This study evaluates the anesthesia approach applied to the injured who were transferred to our tertiary hospital. METHODS: We retrospectively reviewed the data of patients who underwent surgery between February 6 and February 20, 2023. The study included earthquake victims who underwent emergency trauma surgery, aged 10 years and above. We recorded the date of admission to the hospital, demographic information, type of surgery, surgical site, anesthesia technique, preference for peripheral block, laboratory values, dialysis and intensive care needs, and survival rates. Data analysis was performed using the IBM® Statistical Package for the Social Sciences (SPSS®) Version 26.0. RESULTS: A total of 375 cases were included in the study. Of these, 323 patients underwent surgery for extremity injuries, and 35 for vertebral injuries. Among the extremity injuries, 61.6% were to the lower extremities, and 17.1% to the upper extremities. Debridement was performed on 147 patients, fasciotomy on 49 patients, and amputation on 33 patients. General anesthesia was applied to 352 patients, spinal anesthesia to 19 patients, and sedoanalgesia to four patients. Peripheral nerve block was performed on 33 patients. Dialysis treatment was administered to 105 patients. Twenty-six patients were lost during the treatment process. There were no intraoperative patient deaths. CONCLUSION: The predominance of extremity injuries among earthquake victims increases the inclination towards regional anesthesia. Incorporating Plan A blocks into basic anesthesia skills could enhance the preference for regional anesthesia in disaster situations. Furthermore, transferring the injured to advanced centers may reduce morbidity.

Access to Otolaryngologic Telemedicine Care Across the COVID-19 Pandemic at an Urban Tertiary Hospital System.

Objective: To describe associations between patients' demographic characteristics and access to telemedicine services in an urban tertiary academic medical system across the COVID-19 pandemic, and to identify potential barriers to access. Methods: This was a retrospective cohort study conducted at a single-center tertiary academic medical center. The study included adult patients undergoing outpatient otolaryngologic care in person or via telemedicine during 8 week timeframes: before the pandemic, at the onset of the pandemic, and during later parts of the pandemic. Patients were characterized by age, sex, race, insurance type, primary language, portal activation status, income estimate, and visit type. Where appropriate, chi-squared tests, Wilcoxon signed-rank tests, and logistic regression were used to compare demographic factors between the cohorts. Results: A total of 14,240 unique patients [median age, 58 years (range, 18-107 years); 56.5% were female] resulting in a total of 29,457 visits (94.8% in-person and 5.2% telemedicine) were analyzed. Patients seen in person were older than those using telemedicine. Telemedicine visits included a higher proportion of patients with private insurance, and fewer patients with government or no insurance compared to in-person visits. Race, income, and English as primary language were not found to have a significant effect on telemedicine use. Conclusion: In an urban tertiary medical center, we found significant differences in sociodemographic characteristics between patients who accessed otolaryngologic care in person versus via telemedicine through different phases of the COVID pandemic, reflecting possible barriers to care associated with telemedicine. Further studies are needed to develop interventions to improve access.

Morbidity and mortality of common femoral endarterectomy.

OBJECTIVE: Common femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. METHODS: Consecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. RESULTS: A total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). CONCLUSIONS: Although commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.