Magnitude and Time-Trends of Post-Endoscopy Esophageal Adenocarcinoma and Post-Endoscopy Esophageal Neoplasia in a Population-Based Cohort Study: The Nordic Barrett's Esophagus Study.

BACKGROUND & AIMS: Post-endoscopy esophageal adenocarcinoma (PEEC) and post-endoscopy esophageal neoplasia (PEEN) undermine early cancer detection in Barrett's esophagus (BE). We aimed to assess the magnitude and conduct time-trend analysis of PEEC and PEEN among patients with newly diagnosed BE. METHODS: This population-based cohort study was conducted in Denmark, Finland, and Sweden between 2006 and 2020 and included 20,588 patients with newly diagnosed BE. PEEC and PEEN were defined as esophageal adenocarcinoma (EAC) or high-grade dysplasia (HGD)/EAC, respectively, diagnosed 30-365 days from BE diagnosis (index endoscopy). HGD/EAC diagnosed from 0-29 days and HGD/EAC diagnosed >365 days from BE diagnosis (incident HGD/EAC) were assessed. Patients were followed up until HGD/EAC, death, or end of study period. Incidence rates (IR) per 100,000 person-years with 95% confidence interval (95% CI) were calculated using Poisson regression. RESULTS: Among 293 patients diagnosed with EAC, 69 (23.5%) were categorized as PEEC, 43 (14.7%) as index EAC, and 181 (61.8%) as incident EAC. The IRs/100,000 person-years for PEEC and incident EAC were 392 (95% CI, 309-496), and 208 (95% CI, 180-241), respectively. Among 279 patients diagnosed with HGD/EAC (Sweden only), 17.2% were categorized as PEEN, 14.6% as index HGD/EAC, and 68.1% as incident HGD/EAC. IRs/100,000 person-years for PEEN, and incident HGD/EAC were 421 (95% CI, 317-558), and 285 (95% CI, 247-328), respectively. Sensitivity analyses that varied time interval for occurrence of PEEC/PEEN demonstrated similar results. A time-trend analysis for IRs demonstrated rising incidence rates of PEEC/PEEN. CONCLUSIONS: Almost a quarter of all EACs are detected within a year after an ostensibly negative upper endoscopy in patients with newly diagnosed BE. Interventions to improve detection may reduce PEEC/PEEN rates.

Understanding the causes of missingness in primary care: a realist review.

BACKGROUND: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single 'situational' missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more 'enduring' multiple missed appointments in primary care and the role this has in producing health inequalities. METHODS: We conducted a realist review of the literature on multiple missed appointments to identify the causes of 'missingness.' We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation. RESULTS: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is 'for them'; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place. CONCLUSIONS: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

Association between ACE1 and missed abortion: ACE1 promotes H2O2-induced trophoblast cell injury in vitro†.

The aim of this study was to evaluate the role of angiotensin-converting enzyme 1 (ACE1) in H2O2-induced trophoblast cell injury and the potential molecular mechanisms. Oxidative stress was modeled by exposing HTR-8/SVneo cells to 200 µM H2O2. Western blot and real-time quantitative PCR methods were used to detect protein and mRNA expression level of ACE1 in chorionic villus tissue and trophoblast HTR-8/SVneo cell. Inhibition of ACE1 expression was achieved by transfection with small interfering RNA. Then flow cytometry, Cell Counting Kit-8, and Transwell assay was used to assess apoptosis, viability, and migration ability of the cells. Reactive oxygen species (ROS) were detected by fluorescent probes, and malondialdehyde (MDA), superoxide dismutase (SOD), and reduced glutathione (GSH) activities were determined by corresponding detection kits. Angiotensin-converting enzyme 1 expression was upregulated in chorionic villus tissue of patients with missed abortion (MA) compared with individuals with normal early pregnancy abortion. H2O2 induced elevated ACE1 expression in HTR-8/SVneo cells, promoted apoptosis, and inhibited cell viability and migration. Knockdown of ACE1 expression inhibited H2O2-induced effects to enhance cell viability and migration and suppress apoptosis. Additionally, H2O2 stimulation caused increased levels of ROS and MDA and decreased SOD and GSH activity in the cells, whereas knockdown of ACE1 expression led to opposite changes of these oxidative stress indicators. Moreover, knockdown of ACE1 attenuated the inhibitory effect of H2O2 on the Nrf2/HO-1 pathway. Angiotensin-converting enzyme 1 was associated with MA, and it promoted H2O2-induced injury of trophoblast cells through inhibiting the Nrf2 pathway. Therefore, ACE1 may serve as a potential therapeutic target for MA.

Development and Validation of Machine Learning Models for Identifying Prediabetes and Diabetes in Normoglycemia.

BACKGROUND: Prediabetes and diabetes are both abnormal states of glucose metabolism (AGM) that can lead to severe complications. Early detection of AGM is crucial for timely intervention and treatment. However, fasting blood glucose (FBG) as a mass population screening method may fail to identify some individuals who are actually AGM but with normoglycemia. This study aimed to develop and validate machine learning (ML) models to identify AGM among individuals with normoglycemia using routine health check-up indicators. METHODS: According to the American Diabetes Association (ADA) criteria, participants with normoglycemia (FBG ≤ 5.6 mmol/L) were collected from 2019 to 2023, and then divided into AGM and Normal groups using glycosylated haemoglobin (HbA1c) 5.7% as the threshold. Data from 2019 to 2022 were divided into training and internal validation sets at a 7:3 ratio, while data from 2023 were used as the external validation set. Seven ML algorithms-including logistic regression (LR), random forest (RF), support vector machine (SVM), extreme gradient boosting machine, multilayer perceptron (MLP), light gradient boosting machine (LightGBM), and categorical boosting (CatBoost)-were used to build models for identifying AGM in normoglycemia population. Model performance was evaluated using the area under the receiver operating characteristic curve (auROC) and the precision-recall curve (auPR). The feature contributions to the optimal model was visualised using the SHapley Additive exPlanations (SHAP). Finally, an intuitive and user-friendly interactive interface was developed. RESULTS: A total of 59,259 participants were finally enroled in this study, and then divided into the training set of 32,810, the internal validation set of 14,060, and the external validation set of 12,389. The Catboost model outperformed the others with auROC of 0.806 and 0.794 for the internal and external validation set, respectively. Age was the most important feature influencing the performance of the CatBoost model, followed by fasting blood glucose, red blood cells, haemoglobin, body mass index, and triglyceride-glucose. CONCLUSION: A well-performed ML model to identify AGM in the normoglycemia population was built, offering significant potential for early intervention and treatment of AGM that would otherwise have been missed.

Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study.

BACKGROUND: Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. OBJECTIVE: To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. MAIN MEASURES: Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. KEY RESULTS: The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively. CONCLUSIONS: Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.

The relationship between thyroid autoantibodies and X chromosome monosomy in the chorionic tissue of patients with missed miscarriage.

OBJECTIVE: The aim of this study was to investigate the relationship between thyroid autoantibodies (TGAb and TPOAb) and X chromosome monosomy in the chorionic tissue of patients with missed early miscarriage. METHODS: The baseline data, thyroid function, thyroid antibody and the chromosomes from the chorionic tissue of 228 patients with missed early miscarriage were examined. RESULTS: (1) Among the 228 patients, 121 had a normal chromosome number, and 107 had an abnormal chromosome number. The majority of them were autosomal trisomy, of which trisomy 16 (40.19%) was predominant. Sex chromosome monosomy (28.04%) was secondary. (2) Among the 228 patients, 208 patients in this study had normal thyroid function (including 134 cases of negative thyroid antibodies and 74 cases of positive thyroid antibodies alone); 6 patients had abnormal thyroid function (including 2 cases of clinical hyperthyroidism, 3 cases of subclinical hypothyroidism, 1 case of hypothyroxinemia); and 14 patients had normal TSH and elevated T4 alone.(3) After exclusion of patients with thyroid function abnormalities, there were no significant differences in baseline data between the normal chromosome group and the abnormal chromosome group (P > 0.05). However, there was a significant difference in TGAb and TPOAb between the normal chromosome and abnormal chromosome group with 45, X karyotype, with a higher proportion of TGAb and/or TPOAb positivity in the 45, X karyotype group (P < 0.05). Additionally, compared to TGAb and/or TPOAb-positive patients, the risk of X chromosome monosomy was significantly reduced in TGAb and TPOAb-negative patients (P < 0.05). Moreover, both TGAb and TPOAb titer values in the X chromosome monosomy group were higher than those in the chromosomally normal group (P < 0.05). CONCLUSION: There is a correlation between TGAb, TPOAb and X chromosome monosomy in the chorionic tissue of patients with missed early miscarriage, although the mechanism remains to be further investigated.

During the COVID-19 pandemic 20 000 prostate cancer diagnoses were missed in England.

OBJECTIVES: To investigate the effect of the COVID-19 pandemic on prostate cancer incidence, prevalence, and mortality in England. PATIENTS AND METHODS: With the approval of NHS England and using the OpenSAFELY-TPP dataset of 24 million patients, we undertook a cohort study of men diagnosed with prostate cancer. We visualised monthly rates in prostate cancer incidence, prevalence, and mortality per 100 000 adult men from January 2015 to July 2023. To assess the effect of the pandemic, we used generalised linear models and the pre-pandemic data to predict the expected rates from March 2020 as if the pandemic had not occurred. The 95% confidence intervals (CIs) of the predicted values were used to estimate the significance of the difference between the predicted and observed rates. RESULTS: In 2020, there was a drop in recorded incidence by 4772 (31%) cases (15 550 vs 20 322; 95% CI 19 241-21 403). In 2021, the incidence started to recover, and the drop was 3148 cases (18%, 17 950 vs 21 098; 95% CI 19 740-22 456). By 2022, the incidence returned to the levels that would be expected. During the pandemic, the age at diagnosis shifted towards older men. In 2020, the average age was 71.6 (95% CI 71.5-71.8) years, in 2021 it was 71.8 (95% CI 71.7-72.0) years as compared to 71.3 (95% CI 71.1-71.4) years in 2019. CONCLUSIONS: Given that our dataset represents 40% of the population, we estimate that proportionally the pandemic led to 20 000 missed prostate cancer diagnoses in England alone. The increase in incidence recorded in 2023 was not enough to account for the missed cases. The prevalence of prostate cancer remained lower throughout the pandemic than expected. As the recovery efforts continue, healthcare should focus on finding the men who were affected. The research should focus on investigating the potential harms to men diagnosed at older age.

Effect of different working periods on missed diagnosis of colorectal polyps in colonoscopy.

BACKGROUND: To investigate the effect of different working periods on missed diagnoses in patients with colorectal polyps in colonoscopy. METHODS: We conducted a retrospective analysis of patients who were diagnosed with colorectal polyps during colonoscopy in an outpatient department between July and December 2022. These patients were subsequently hospitalized for resection during this period. Patients with missed diagnoses were those who had newly discovered polyps in a second colonoscopy. The working periods were categorized as work, near the end of work, and delayed work, respectively, in the morning and afternoon. RESULTS: A total of 482 patients were included, and the miss rate of diagnosis was 48.1% (232/482), mainly in the transverse colon (25%), and the ascending colon (23%). Patient age was a risk factor for the miss rate of diagnosis (OR = 1.025, 95%CI: 1.009-1.042, P = 0.003) and was also associated with the number of polyps detected for the first colonoscopy (χ2 = 18.196, P = 0.001). The different working periods had no statistical effect on the missed rate of diagnosis (χ2 = 1.998, P = 0.849). However, there was an increasing trend in miss rates towards the end of work and delayed work periods, both in the morning and afternoon. The highest miss rate (60.0%) was observed during delayed work in the afternoon. Additionally, poor bowel preparation was significantly more common during delayed work in the afternoon. CONCLUSIONS: The increasing trend in miss rates towards the end of work and delayed work periods deserves clinical attention. Endoscopists cannot always stay in good condition under heavy workloads.

Syndromic case definitions for lower respiratory tract infection (LRTI) are less sensitive in older age: an analysis of symptoms among hospitalised adults.

BACKGROUND: Lower Respiratory Tract Infections (LRTI) pose a serious threat to older adults but may be underdiagnosed due to atypical presentations. Here we assess LRTI symptom profiles and syndromic (symptom-based) case ascertainment in older (≥ 65y) as compared to younger adults (< 65y). METHODS: We included adults (≥ 18y) with confirmed LRTI admitted to two acute care Trusts in Bristol, UK from 1st August 2020- 31st July 2022. Logistic regression was used to assess whether age ≥ 65y reduced the probability of meeting syndromic LRTI case definitions, using patients' symptoms at admission. We also calculated relative symptom frequencies (log-odds ratios) and evaluated how symptoms were clustered across different age groups. RESULTS: Of 17,620 clinically confirmed LRTI cases, 8,487 (48.1%) had symptoms meeting the case definition. Compared to those not meeting the definition these cases were younger, had less severe illness and were less likely to have received a SARS-CoV-2 vaccination or to have active SARS-CoV-2 infection. Prevalence of dementia/cognitive impairment and levels of comorbidity were lower in this group. After controlling for sex, dementia and comorbidities, age ≥ 65y significantly reduced the probability of meeting the case definition (aOR = 0.67, 95% CI:0.63-0.71). Cases aged ≥ 65y were less likely to present with fever and LRTI-specific symptoms (e.g., pleurisy, sputum) than younger cases, and those aged ≥ 85y were characterised by lack of cough but frequent confusion and falls. CONCLUSIONS: LRTI symptom profiles changed considerably with age in this hospitalised cohort. Standard screening protocols may fail to detect older and frailer cases of LRTI based on their symptoms.

Comparing letrozole and mifepristone pre-treatment in medical management of first trimester missed miscarriage: a prospective open-label non-inferiority randomised controlled trial.

OBJECTIVE: To investigate whether letrozole pre-treatment is non-inferior to mifepristone pre-treatment, followed by misoprostol, for complete evacuation in the medical treatment of first-trimester missed miscarriage. DESIGN: Prospective open-label non-inferiority randomised controlled trial. SETTING: A university-affiliated hospital. POPULATION: We recruited 294 women diagnosed with first-trimester missed miscarriage who opted for medical treatment. METHODS: Participants were randomly assigned to: (i) the mifepristone group, who received 200 mg mifepristone orally followed 24-48 h later by 800 µg misoprostol vaginally; or (ii) the letrozole group, who received 10 mg letrozole orally once-a-day for 3 days, followed by 800 µg misoprostol vaginally on the third (i.e. last) day of letrozole administration. MAIN OUTCOME MEASURES: The primary outcome was the rate of complete evacuation without surgical intervention at 42 days post-treatment. Secondary outcomes included induction-to-expulsion interval, adverse effects, women's satisfaction, number of doses of misoprostol required, duration of vaginal bleeding, pain score on the day of misoprostol administration and other adverse events. RESULTS: The complete evacuation rates were 97.8% (95% CI 95.1%-100%) and 97.2% (95% CI 94.4%-99.9%) in the letrozole and mifepristone groups, respectively (p ≤ 0.001 for non-inferiority). The mean induction-to-tissue expulsion interval in the letrozole group was longer compared with the mifepristone group (15.4 vs 9.0 h) (p = 0.03). The letrozole group had less heavy post-treatment bleeding and an earlier return of menses. There were no statistically significant differences in the number of doses of misoprostol required, the duration of vaginal bleeding, the pain score on the day of misoprostol administration and the rate of other adverse events between the two groups. The majority of the women (91.2% and 93.9% in the letrozole and mifepristone groups, respectively) were satisfied with their treatment option. CONCLUSIONS: Letrozole is non-inferior to mifepristone as a pre-treatment, followed by misoprostol, for the medical treatment of first-trimester missed miscarriage.

Evaluation of a Pharmacist-Led Implementation of Standardized Medication Administration Times for Inpatients Receiving Hemodialysis.

BACKGROUND: Missed medication doses are a common and often preventable medication-related error that have been associated with an increased length of stay and mortality. Hemodialysis is a common, relatively predictable reason that patients are unavailable, resulting in missed doses. OBJECTIVE: To evaluate the implications of a pharmacist-led intervention to standardize the medication administration times for patients requiring hemodialysis who were prescribed antihypertensives, antiepileptics, apixaban, and/or antimicrobials. METHODS: A retrospective preanalysis and postanalysis of a pharmacist-led intervention were performed at a single-center, safety net hospital. Patients receiving dialysis and prescribed one of the targeted medications were included. The primary endpoint was the composite of missed and delayed doses. RESULTS: A total of 25 patients receiving 126 dialysis sessions in the preintervention group and 29 patients receiving 80 dialysis sessions in the postintervention group were included for analysis. For the primary endpoint, 118 (18%) versus 57 (9.3%) doses were missed or delayed in the preintervention versus postintervention group, respectively (P < 0.001). The primary endpoint was driven by fewer delayed doses in the postgroup. The number of antimicrobials given on a correct schedule increased in the postintervention group (98.3% vs 99.1%, P = 0.044). CONCLUSION AND RELEVANCE: A pharmacist-led intervention for standard medication administration times in patients requiring hemodialysis increased the number of prescribed medication doses given and given on time. The intervention also led to more antimicrobials administered at appropriate times relative to dialysis sessions.

Analysis of missed clinic visits, preferred languages, and telemedicine in a pediatric gastroenterology practice.

OBJECTIVES: Previous studies have demonstrated a relationship between socioeconomic disparities and missed clinic visits (MCV). However, the relationship between patient-preferred language and MCVs, particularly with respect to telemedicine, remains relatively underexplored. We sought to characterize the associations between MCV and patient-level predictors, including preferred language, in a large single-center pediatric gastroenterology, hepatology, and nutrition practice. METHODS: This retrospective longitudinal cohort study included all missed or completed outpatient visits in the Gastroenterology, Hepatology, and Nutrition Programs at Boston Children's Hospital from January 1, 2016 to May 20, 2022. Univariate and multivariate hierarchical generalized linear mixed models were employed to identify associations between visit- and patient-level predictors and an MCV outcome. RESULTS: A total of 300,201 visits from 70,710 patients residing in Massachusetts were included. Univariate analyses revealed higher MCV odds for Hispanic patients and those from areas with the highest Social Vulnerability Index (SVI), and these odds increased with telemedicine (Hispanic in-person odds ratio [OR] 5.21 [(95% confidence interval) 4.93-5.52] vs. telemedicine OR 8.79 [7.85-9.83]; highest SVI in-person OR 5.28 [4.95-5.64] vs. telemedicine OR 7.82 [6.84-8.96]). Controlled multivariate analyses revealed that among six language groups, only Spanish language preference was associated with higher MCV odds, which increased with telemedicine (Spanish in-person adjusted OR [aOR] 1.35 [1.24-1.48] vs. telemedicine aOR 2.1 [1.83-2.44]). CONCLUSIONS: Patients preferring Spanish experience unique barriers to care beyond those faced by other language preference groups, and telemedicine may exacerbate these barriers.

Missed and Delayed Diagnoses of Chronic Liver Disease in Primary Care Patients with Cirrhosis.

BACKGROUND: Chronic liver diseases (CLD), cirrhosis, and hepatocellular carcinoma (HCC) cause significant morbidity and mortality. Unfortunately, patients with CLD often go undiagnosed until progression to cirrhosis and HCC. We aimed to determine the proportion of primary care patients with severe liver disease outcomes that had missed or delayed CLD diagnoses. METHODS: This retrospective cohort study evaluated primary care patients with a diagnosis of cirrhosis, HCC, or other severe liver disease outcome between 2012 and 2021. The outcomes of interest were missed and delayed diagnoses of CLD, defined as the absence of a CLD diagnosis (missed) or first appearance of CLD on the same day as the cirrhosis diagnosis (delayed). Univariate analyses were performed to describe the cohort. Multivariable logistic regression models analyzed the association of aminotransferase elevations with the outcomes of interest. RESULTS: Of 667 patients with cirrhosis or HCC, 133 (20%) had a missed CLD diagnosis, and 243 (36%) had a delayed CLD diagnosis. Alcohol-related liver disease was the most common etiology among patients with missed/delayed diagnoses. A lower proportion of patients with missed/delayed diagnoses had an elevation in ALT or AST compared to patients with timely diagnoses (61% vs. 77%, p < 0.001). Elevated aminotransferase values were associated with lower odds of a missed/delayed diagnosis (OR 0.47; 95%CI 0.34-0.66). CONCLUSIONS: Most patients with cirrhosis or HCC had missed or delayed diagnoses of CLD in the context of probable overreliance on aminotransferase elevation for CLD detection. Enhanced screening for high prevalence CLD, especially alcohol, in primary care is needed.

High-risk factors for massive haemorrhage in medical abortion patients with missed miscarriage.

BACKGROUND: Recently, the incidence of missed miscarriage has gradually increased, and medical abortion is a common method to terminate a pregnancy. In the process of medical abortion, massive vaginal bleeding takes place, leading to emergency surgical haemostasis. Emergency surgery may produce infection and organ damage. Our study aimed to investigate the high-risk factors for massive haemorrhage during a medical abortion. METHODS: A total of 1062 missed miscarriage patients who underwent medical abortion participated in this retrospective study. According to the amount of bleeding, the patients were divided into a massive haemorrhage group and a control group. By comparing the general conditions of the two groups, such as fertility history, uterine surgery history, uterine fibroids, etc., the high-risk factors for massive haemorrhage during medical abortion were identified. RESULTS: Relative to the control group, the massive haemorrhage group exhibited a higher proportion of patients with a previous artificial abortion (51.9% vs. 38.1%, P = 0.001). Additionally, the massive haemorrhage group had a lower percentage of first-time pregnant women (32.1% vs. 40.4%) and a higher proportion of women with shorter pregnancy intervals (44.9% vs. 33.1%, P = 0.03). Furthermore, there were notable differences between the two groups regarding maximum fibroid size, the duration of amenorrhea, and gestational week (P < 0.05). CONCLUSION: In this study, we determined that a history of artificial abortion and an amenorrhea duration of > 11 weeks represented high-risk factors for massive vaginal bleeding during medical abortion in missed miscarriage patients.

"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes.

BACKGROUND: A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?" METHODS: A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway. RESULTS: Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes. CONCLUSIONS: Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Childcare needs as a barrier to healthcare among women in a safety-net health system.

BACKGROUND: Childcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population. METHODS: We conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers. RESULTS: Among the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs. CONCLUSIONS: Childcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Donor audits in deceased organ donation: a scoping review.

PURPOSE: We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance. SOURCE: We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement. PRINCIPAL FINDINGS: The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD. CONCLUSION: Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

RéSUMé: OBJECTIF: Nous avons cherché à colliger et résumer la documentation existante sur les vérifications des donneuses et donneurs (VD) et la façon dont elles ont été utilisées pour guider la performance et l'assurance de la qualité des systèmes de don et de transplantation d'organes de personnes décédées. SOURCES: Le 6 mai 2022, nous avons effectué des recherches dans MEDLINE, CINAHL et Web of Science, complétées par des recherches sur Google afin d'identifier la littérature grise et de localiser les études en anglais, en français et en espagnol. Les données ont été examinées, extraites et analysées de manière indépendants par deux personnes. Nous avons regroupé les résultats en cinq catégories : 1) motivation pour la VD, 2) méthodologie de la VD, 3) donneurs et donneuses potentiel·les et réel·les, 4) occasions de dons manquées, et 5) amélioration de la qualité. CONSTATATIONS PRINCIPALES: Notre recherche nous a permis de découvrir 2416 publications uniques et 52 ont été incluses dans cette revue. La plupart des études provenaient du Royaume-Uni (n = 13) et avaient été publiées entre 2001 et 2006 (n = 15). Les méthodologies décrites pour la vérification des donneuses et donneurs étaient diverses. Nos résultats ont montré que la principale motivation pour mener une VD était d'identifier des donneurs et donneuses potentiel·les et que le nombre potentiel de donneuses et donneurs d'organes après le décès était significativement plus élevé que le nombre réel. Parmi les études retenues, la proportion d'occasions de dons après un diagnostic de décès neurologique était de 95/222 (43 %), comparativement à 25/181 (14 %) pour le don après un décès cardiocirculatoire (DDC), ce qui suggère que le taux de dons manqués est plus élevé pour le DDC. CONCLUSION: Les vérifications des donneuses et donneurs aident à identifier les occasions de dons manquées le long du parcours de don après un décès et peuvent aider à soutenir l'évaluation des initiatives d'amélioration de la qualité.

Unveiling missed nursing care: a comprehensive examination of neglected responsibilities and practice environment challenges.

BACKGROUND: The global variable of missed nursing care and practice environment are widely recognized as two crucial contextual factors that significantly impact the quality of nursing care. This study assessed the current status of missed nursing care and the characteristics of the nursing practice environment in Iran. Additionally, this study aimed to explore the relationship between these two variables. METHODS: We conducted an across-sectional study from May 2021 to January 2022 in which we investigated 255 nurses. We utilized the Missed Nursing Care Survey, the Nursing Work Index-Practice Environment Scale, and a demographic questionnaire to gather the necessary information. We used the Shapiro‒Wilk test, Pearson correlation coefficient test, and multiple linear regression test in SPSS version 20 for the data analyses. RESULTS: According to the present study, 41% of nurses regularly or often overlooked certain aspects of care, resulting in an average score of 32.34 ± 7.43 for missed nursing care. It is worth noting that attending patient care conferences, providing patient bathing and skin care, and assisting with toileting needs were all significant factors contributing to the score. The overall practice environment was unfavorable, with a mean score of 2.25 ± 0.51. Interestingly, 'nursing foundations for quality of care' was identified as the sole predictor of missed nursing care, with a ß value of -0.22 and a p-value of 0.036. CONCLUSIONS: This study identified attending patient care interdisciplinary team meetings and delivering basic care promptly as the most prevalent instances of missed nursing care. Unfortunately, the surveyed hospitals exhibited an undesirable practice environment, which correlated with a higher incidence of missed nursing care. These findings highlight the crucial impact of nurses' practice environment on care delivery. Addressing the challenges in the practice environment is essential for reducing instances of missed care, improving patient outcomes, and enhancing overall healthcare quality.

The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study.

OBJECTIVES: This prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). METHODS: We recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 µg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. RESULTS: Overall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. CONCLUSIONS: Pretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.

Decision analysis framework for predicting no-shows to appointments using machine learning algorithms.

BACKGROUND: No-show to medical appointments has significant adverse effects on healthcare systems and their clients. Using machine learning to predict no-shows allows managers to implement strategies such as overbooking and reminders targeting patients most likely to miss appointments, optimizing the use of resources. METHODS: In this study, we proposed a detailed analytical framework for predicting no-shows while addressing imbalanced datasets. The framework includes a novel use of z-fold cross-validation performed twice during the modeling process to improve model robustness and generalization. We also introduce Symbolic Regression (SR) as a classification algorithm and Instance Hardness Threshold (IHT) as a resampling technique and compared their performance with that of other classification algorithms, such as K-Nearest Neighbors (KNN) and Support Vector Machine (SVM), and resampling techniques, such as Random under Sampling (RUS), Synthetic Minority Oversampling Technique (SMOTE) and NearMiss-1. We validated the framework using two attendance datasets from Brazilian hospitals with no-show rates of 6.65% and 19.03%. RESULTS: From the academic perspective, our study is the first to propose using SR and IHT to predict the no-show of patients. Our findings indicate that SR and IHT presented superior performances compared to other techniques, particularly IHT, which excelled when combined with all classification algorithms and led to low variability in performance metrics results. Our results also outperformed sensitivity outcomes reported in the literature, with values above 0.94 for both datasets. CONCLUSION: This is the first study to use SR and IHT methods to predict patient no-shows and the first to propose performing z-fold cross-validation twice. Our study highlights the importance of avoiding relying on few validation runs for imbalanced datasets as it may lead to biased results and inadequate analysis of the generalization and stability of the models obtained during the training stage.