This process evaluation explores patient and healthcare professional acceptability of community-based monitoring versus hospital-based care for patients with quiescent neovascular age-related macular degeneration (QnAMD). Qualitative process evaluation was conducted as part of a randomised controlled trial. Six hospitals and six community-based practices. 25 patients and 16 healthcare professionals (ophthalmologists and optometrists). This approach helped differentiate between common issues and those specific to community-based monitoring. The Quality-Assured Follow-Up of QnAMD by non-medical practitioners trial aimed to examine whether non-medical practitioners follow-up patients with QnAMD in the community in a safe and clinically and cost-effective way. The process evaluation aimed to examine whether the intervention was acceptable by patients and professionals. The process evaluation was based on interviews which contained open-ended questions focused on patient experience and confidence in community-based care, issues concerning the practicalities of the organisation and management of the clinic, and resources including IT and digital equipment. The theory of acceptability framework was used to interpret the findings. Patients reported positively on the experience of receiving QnAMD services in the community and highlighted staff professionalism and clear communication. Key themes were the proximity of care provision for patients, IT interoperability and the real-world costs of running the service. Some patients randomised to the hospital showed preference for the intervention to take place in the hospital, mediated mainly by prior experience of hospital care and travel distance. The location of the clinic and transport routes affected the experience of attending appointments, with strong preference expressed for proximity to one's home. Inaccessibility due to non-modifiable internal building structures in the community and parking in hospital eye services was reported by a small proportion of patients. Healthcare professionals reported positively about their ability to deliver QnAMD services in community settings but raised concerns about the compatibility of technological infrastructure that facilitates the sharing of optical coherence tomography image and video files. Some optometrists were also concerned about the financial sustainability of the intervention after the end of the trial due to the costs involved in the administration of QnAMD follow-up care. The delivery of QnAMD services in the community by non-medical personnel was broadly accepted by both patients and practitioners. This implies that non-medical practitioners can follow up patients with QnAMD in the community in a safe way. Further research would be needed to establish whether similar results would be obtained during routine practice outside a research project and whether the long-term follow-up for QnAMD would be financially sustainable for independent as well as chain community optometry practices. NCT03893474.
Fewer than 2500 physicians nationwide are certified in addiction medicine. Inpatient addiction hospitalist services have been shown to improve patient outcomes, but their capabilities and impact are underexplored in community hospitals. This study evaluates the role of an addiction medicine hospitalist service in enhancing patient outcomes in two community-based hospitals. A retrospective chart review was conducted on patients who received care from addiction medicine service in two hospitals. The data were collected within the first 120 days of the establishment of service. The reason for consultation, substances used, types of management, impact on transition of care, readmissions and length of stay were evaluated. 152 patients were seen by the addiction medicine service during the study period. Majority of consultations came from internal medicine followed by general surgery, family medicine, burns and maternity. Ongoing substance use accounted for 47.7 % of consultations, 31.8 % for managing withdrawal, and 21.9 % for managing overdose and toxicity. Medications for alcohol use disorder were started in 87.5 % of cases and opioid use disorder in 96 %. Buprenorphine was the most commonly initiated medication for opioid use disorder and naltrexone for alcohol use disorder. In 14.7 % of cases, the service made a positive impact on length of stay. The readmission rate in these patients was 8.4 % as compared to 13 % for all the patients admitted to the hospital during the study period. Addiction medicine hospitalist service can offer quality care to a wide variety of SUDs in a community hospital setting and supports multiple services.
Changes in the U.S. healthcare system have led to graduate medical education (GME) programs expanding beyond academic medical centers to community hospitals. Direct-care physicians at these hospitals are now responsible for supervising trainees, requiring them to develop new skills in education. This article describes how our educational development office collaborated with community hospital GME program directors to pilot faculty development programming to integrate community hospital physicians into trainee education. We met with program directors for two GME community programs, reviewed topics that would be most helpful to clinicians who are unfamiliar with education, and organized workshops to prepare them for their expanded role. Workshops were facilitated at the respective hospital locations and recorded for future reference. We administered surveys after each session and interviewed program directors to evaluate the workshops' impact. Overall, we conducted a total of 14 one-hour workshops. Program director interview results showed buy-in from faculty members regarding learning how to be effective teachers. Faculty also expressed greater confidence in engaging with learners after the workshops. Some areas of improvement were increased awareness and promotion of session offerings and the integration of clinician co-presenters. By engaging GME program directors at community hospitals in creating educational development programs for their faculty, we provided crucial support to build teaching capacity for direct-care physicians. This blueprint provides guidance for others to more quickly implement educational training for direct-care physicians and is relevant for other independent academic medical centers seeking ways to support their community hospitals with new GME programs.
Community-based internal medicine residencies train nearly half of all U.S. IM residents and are essential for staffing underserved areas. These programs often face educational gaps due to limited resources, faculty development, and procedural training opportunities. We designed a 12-month quality initiative for 27 residents at a small community hospital blending new high-fidelity simulation drills (e.g. in-situ rapid-response and procedural labs), restructured didactics (gamified quizzes, NEJM Resident 360™, HumanDx cases), enhanced orientation ("intern survival guide"), research education, wellness retreats, community outreach and AI-driven, individualized case feedback. New interventions were implemented alongside existing activities, with targeted outcomes including clinical competency, board readiness, communication skills, and well-being. Over one year, the mean In-Training Examination (ITE) scores rose from 56.7 % to 59.9 % (p = 0.025) and percentile rank by 11.8 points, CAHPS patient communication scores improved from the 66th to 97th percentile (p < 0.05), and resident satisfaction (ACGME survey) increased from 70 % to 84 %. 78 % of residents found simulation "very useful," while 74 % felt supported by wellness initiatives. Gamified learning was highly relevant to 44 %. Sustained impact needs continued leadership and formal GME integration. Investing in resident education directly improves patient care, creating a continuous cycle of clinical excellence.
Lower respiratory infections (LRIs) remain the world's leading infectious cause of death. This analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides global, regional, and national estimates of LRI incidence, mortality, and disability-adjusted life-years (DALYs), with attribution to 26 pathogens, including 11 newly modelled pathogens, across 204 countries and territories from 1990 to 2023. With new data and revised modelling techniques, these estimates serve as an update and expansion to GBD 2021. Through these estimates, we also aimed to assess progress towards the 2025 Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) target for pneumonia mortality in children younger than 5 years. Mortality from LRIs, defined as physician-diagnosed pneumonia or bronchiolitis, was estimated using the Cause of Death Ensemble model with data from vital registration, verbal autopsy, surveillance, and minimally invasive tissue sampling. The Bayesian meta-regression tool DisMod-MR 2.1 was used to model overall morbidity due to LRIs. DALYs were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs) for all locations, years, age groups, and sexes. We modelled pathogen-specific case-fatality ratios (CFRs) for each age group and location using splined binomial regression to create internally consistent estimates of incidence and mortality proportions attributable to viral, fungal, parasitic, and bacterial pathogens. Progress was assessed towards the GAPPD target of less than three deaths from pneumonia per 1000 livebirths, which is roughly equivalent to a mortality rate of less than 60 deaths per 100 000 children younger than 5 years. In 2023, LRIs were responsible for 2·50 million (95% uncertainty interval [UI] 2·24-2·81) deaths and 98·7 million (87·7-112) DALYs, with children younger than 5 years and adults aged 70 years and older carrying the highest burden. LRI mortality in children younger than 5 years fell by 33·4% (10·4-47·4) since 2010, with a global mortality rate of 94·8 (75·6-116·4) per 100 000 person-years in 2023. Among adults aged 70 years and older, the burden remained substantial with only marginal declines since 2010. A mortality rate of less than 60 deaths per 100 000 for children younger than 5 years was met by 129 of the 204 modelled countries in 2023. At a super-regional level, sub-Saharan Africa had an aggregate mortality rate in children younger than 5 years (hereafter referred to as under-5 mortality rate) furthest from the GAPPD target. Streptococcus pneumoniae continued to account for the largest number of LRI deaths globally (634 000 [95% UI 565 000-721 000] deaths or 25·3% [24·5-26·1] of all LRI deaths), followed by Staphylococcus aureus (271 000 [243 000-298 000] deaths or 10·9% [10·3-11·3]), and Klebsiella pneumoniae (228 000 [204 000-261 000] deaths or 9·1% [8·8-9·5]). Among pathogens newly modelled in this study, non-tuberculous mycobacteria (responsible for 177 000 [95% UI 155 000-201 000] deaths) and Aspergillus spp (responsible for 67 800 [59 900-75 900] deaths) emerged as important contributors. Altogether, the 11 newly modelled pathogens accounted for approximately 22% of LRI deaths. This comprehensive analysis underscores both the gains achieved through vaccination and the challenges that remain in controlling the LRI burden globally. Furthermore, it demonstrates persistent disparities in disease burden, with the highest mortality rates concentrated in countries in sub-Saharan Africa. Globally, as well as in these high-burden locations, the under-5 LRI mortality rate remains well above the GAPPD target. Progress towards this target requires equitable access to vaccines and preventive therapies-including newer interventions such as respiratory syncytial virus monoclonal antibodies-and health systems capable of early diagnosis and treatment. Expanding surveillance of emerging pathogens, strengthening adult immunisation programmes, and combating vaccine hesitancy are also crucial. As the global population ages, the dual challenge of sustaining gains in child survival while addressing the rising vulnerability in older adults will shape future pneumonia control strategies. Gates Foundation.
A key challenge in pulmonary arterial hypertension (PAH) research is assessing the specific impact of this condition on health-related quality of life (HRQoL), also considering the patient's subjective experience and caregiving burden. The prospective, observational, multicentre Non-INterventional Study on Pulmonary arterial hypertension patients treated with macitentan and/or selexipag: ExperienCe from an ITalIan cOhort (INSPECTIO) study integrated narratives with patient-reported outcomes (PROs) and clinical data to gain deeper insight into patients' experiences of PAH, also involving caregivers' perspectives. The study was conducted across 29 Italian hospital-based centres and enrolled adult patients with PAH already on treatment with macitentan and/or selexipag as part of combination therapy. A dedicated narrative collection was carried out within the larger study. Patient and caregiver narratives were collected at enrolment (visit 1; V1) and at 12 months (visit 3; V3), then analysed through MAXQDA software and correlated with emPHasis-10 questionnaire scores and clinical data. Out of the 186 patients enrolled in the overall INSPECTIO study, 96/186 (52%) completed the narrative at V1 and 58/186 (31%) at V3; 29/54 (54%) caregivers completed the narrative at V1 and 16/54 (30%) at V3. The analysis revealed an alignment between patient narratives and emPHasis-10 scores. Specifically, at V3, emPHasis-10 scores were higher for patients who did not mention their domestic life in narratives, reported feelings of shame or isolation, limitations or breathlessness also in daily activities and reported ongoing treatment-related issues. Nonetheless, at V3, 36/58 (62%) of patients described living with PAH as manageable. The care pathway showed a positive impact on caregivers: their narratives indicated a shift from V1 to V3, with improved perceptions of the care relationship and PAH therapies. INSPECTIO is the first study to integrate narratives, PROs and clinical data in PAH research. Findings suggested that appropriate support and therapeutic management are crucial to help patients cope with the condition. Narratives have proven to be a valuable tool for understanding the impact of PAH and improving its management, providing insights that can inform a more patient-centred approach. NCT04567602.
Breast cancer is a leading cause of mortality and morbidity among females worldwide. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we provided an updated comprehensive assessment of the epidemiological trends, disease burden, and risk factors associated with breast cancer globally, regionally, and nationally from 1990 to 2023. Breast cancer incidence, mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) were estimated by age and sex for 204 countries and territories from 1990 to 2023. Mortality estimates were generated using GBD Cause of Death Ensemble models, leveraging data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Mortality-to-incidence ratios were calculated to derive both mortality and incidence estimates. Prevalence was calculated by combining incidence and modelled survival estimates. YLLs were established by multiplying age-specific deaths with the GBD standard life expectancy at the age of death. YLDs were estimated by applying disability weights to prevalence estimates. The sum of YLLs and YLDs equalled the number of DALYs. Breast cancer burden attributable to seven risk factors was examined through the comparative risk assessment framework. The GBD forecasting framework was used to forecast breast cancer incidence and mortality from 2024 to 2050. Age-standardised rates were calculated for each metric using the GBD 2023 world standard population. In 2023, there were an estimated 2·30 million (95% uncertainty interval [UI] 2·01 to 2·61) breast cancer incident cases, 764 000 deaths (672 000 to 854 000), and 24·1 million (21·3 to 27·5) DALYs among females globally. In the World Bank low-income group, where a low age-standardised incidence rate (ASIR) was estimated (44·2 per 100 000 person-years [31·2 to 58·4]), the age-standardised mortality rate (ASMR) was the highest (24·1 per 100 000 [16·8 to 31·9]). The highest ASIR was in the high-income group (75·7 per 100 000 [67·1 to 84·0]), and the lowest ASMR was in the upper-middle-income group (11·2 per 100 000 [10·2 to 12·3]). Between 1990 and 2023, the ASIR in the low-income group increased by 147·2% (38·1 to 271·7), compared with a 1·2% (-11·5 to 17·2) change in the high-income group. The ASMR decreased in the high-income group, changing by -29·9% (-33·6 to -25·9), but increased by 99·3% (12·5 to 202·9) in the low-income group. The increase in age-standardised DALY rates followed that of ASMRs. Risk factors such as dietary risks, tobacco use, and high fasting plasma glucose contributed to 28·3% (16·6 to 38·9) of breast cancer DALYs in 2023. The risk factors with a decrease in attributable DALYs between 1990 and 2023 were high alcohol use and tobacco. By 2050, the global incident cases of breast cancer among females were forecast to reach 3·56 million (2·29 to 4·83), with 1·37 million (0·841 to 2·02) deaths. The stable incidence and declining mortality rates of female breast cancer in high-income nations reflect success in screening, diagnosis, and treatment. In contrast, the concurrent rise in incidence and mortality in other regions signals health system deficits. Without effective interventions, many countries will fall short of the WHO Global Breast Cancer Initiative's ambitious target of achieving an annual reduction of 2·5% in age-standardised mortality rates by 2040. The mounting breast cancer burden, disproportionately affecting some of the world's most vulnerable populations, will further exacerbate health inequalities across the globe without decisive immediate action. Gates Foundation, St Jude Children's Research Hospital.
Rising rates of serious injection-related infections (SIRI) and hospitalizations have been documented nationally in the context of the ongoing opioid and polysubstance use epidemic in the United States. This qualitative interview study assessed multi-level facilitators and barriers to the implementation of an integrated inpatient opioid use disorder (OUD) and SIRI care intervention among organizational stakeholders in the healthcare setting as a secondary aim of a randomized clinical trial. The PRISM (Practical, Robust, Implementation, and Sustainability Model) implementation science framework guided stakeholder interviews. Eligible stakeholders were at least 18 years old and employed in an inpatient or outpatient care setting that served the study patient population. Qualitative interviews assessed contextual factors that supported or hindered the implementation of the novel study intervention and priorities for sustainability and future investment. Interviews lasted approximately 60 min. Qualitative coding and analysis were conducted in NVivo. Overall, thirteen stakeholders were interviewed, including clinicians from cardiothoracic surgery, hospital medicine, infectious disease, and addiction medicine, hospital administrators, social work and case management staff, pharmacists, Bridge Clinic staff, and staff from home infusion. Within the four overarching PRISM domains thirteen critical elements were activated by the study intervention that represented key barriers and facilitators to implementation, including: Intervention (Coordination across departments, Strength of the evidence base, Burden, Barriers of frontline staff, SUD stigma); Recipients (Clinical leadership, Organizational health and culture; Patient disease burden, Patient demographics); External Environment (Community Resources, Reimbursement); and Implementation and Sustainability Infrastructure (Dedicated team, Plan for sustainability). Examination of implementation determinants highlighted organizational and external barriers and facilitators. Barriers centered on the complexities of care coordination across departments, the inpatient-outpatient transition, and specialized training needs; these appeared modifiable through adoption of specific implementation strategies. The presence of critical clinical infrastructure to support this transitional OUD-SIRI integrated care model was an essential facilitator, which could represent a challenge for other health systems. External factors, including low resource availability, and SUD-related stigma that excludes patients from opportunities to receive care in the community, collectively pose challenges to wider implementation and sustainability.
Infective endocarditis (IE) is a rare cause of myocardial infarction (MI). In contrast to other embolic phenomena associated with IE, the incidence of coronary embolism is <1 % with a mortality rate of >65 %. Common risk factors of IE include intravenous drug use (IVDU), hemodialysis and the use of cardiac devices. We present a unique case of multiple coronary artery involvement on 2 separate occasions highlighting the need for increased awareness among healthcare professionals. A 38-year-old female with history of IVDU, hepatitis B and C presented with acute chest pain and was found to have NSTEMI and active aortic valve vegetation. Left heart catheterization (LHC) revealed an occlusion of the right coronary artery (RCA), which was treated with stent placement. However, on experiencing ventricular fibrillation on hospital day 2, a repeat cardiac catheterization revealed a re-occlusion of RCA proximal to the stent as well as occlusion of the first obtuse marginal artery (OM1). Subsequent investigations also revealed multiple intraparenchymal hemorrhages and probable renal infarcts. The involvement of multiple systems, as well as the occlusion of multiple coronary arteries on separate occasions distinguishes this case from previously reported cases. Timely intervention is critical in the management of MI due to septic embolism. A high index of suspicion and immediate action can be lifesaving. Early diagnostic imaging and percutaneous or surgical interventions can improve patient outcomes. Greater awareness of multisystem and multi-coronary artery embolic phenomena is needed.
Large language models (LLMs) are becoming increasingly popular in medicine and neurosurgery. Because LLMs are not trained in specific subspecialties or diagnoses, a better understanding of the implications, effectiveness, and use of LLMs by users and clinicians is necessary. To better understand LLM's effectiveness in neurosurgery and aneurysms, we compared community and physician feedback on ChatGPT 4o and Gemini 1.5 Flash responses to frequently asked questions regarding brain aneurysms. External surveys were made available on the Brain Aneurysm Foundation page for patients and families to complete and internal surveys were distributed and completed by physicians in the department of neurosurgery at Boston Children's Hospital. In the community survey assessing response usefulness and helpfulness, ChatGPT and Gemini provided different response quality despite similar AI sentiment. Clarity of procedure explanation (p = 0.04), discussion of alternative procedures (p = 0.02), and discussion of procedure risks (p = 0.01) were different. The physician survey, assessing response accuracy, safety, and helpfulness, also found differences in multiple domains. Importantly, differences were found in consistency with current medical knowledge and practice guidelines (p = 0.001), omittance of key points (p < 0.001), and amount of clinically relevant detail included (p < 0.001). LLMs had variable performance across several key domains, consistent with previous research. Despite the apparent advantages of ChatGPT, physician feedback highlighted the continued need for information oversight. Interestingly, community participants consistently found LLM responses to be better than physician ones, while physicians found LLM responses to be similar or somewhat worse than the one they would have provided.
Iron deficiency (ID) is the leading nutritional deficiency and a major public health concern globally. Although anemia is the most widely known consequence of ID, ID is also an underrecognized cause of white blood cell and platelet count abnormalities. The primary objective of the current study is to assess physicians' abilities to diagnose ID. This study is a retrospective chart review of 862 adults (mean age ± SD of 52.5 ± 18.4, 447 female) seen by a classical hematologist at an academic center. Data analysis included specialty type of the referring provider, referral reason, and the diagnosis made by the consulting hematologist. ID was defined as a serum ferritin level <30 ng/mL or <100 ng/mL in the presence of inflammatory comorbidities. Out of 862 initial patient charts, 103 were lost to follow up before completing the workup. Out of the remaining 759 patient charts, 304 (40.0 %) patients received a new diagnosis with ID or iron deficiency anemia (IDA) by the consulting classical hematologist. Of these patients, 21 % were referred from internal medicine (IM), 18 % from family medicine (FM), 14 % from hematology-oncology for a second opinion, and 25 % from other IM subspecialties. In a sub-analysis of 364 patients who had complete blood cell count (CBC) abnormalities, ID was found to play a role in 54.7 % of CBC abnormalities analyzed. This analysis demonstrates that diagnosing ID is a challenge for first-contact physicians and may easily be missed. This leads to delays in ID treatment and resulting clinical consequences.
Patient-Reported Outcomes (PROs) in personalized lung cancer care aim to facilitate a targeted therapeutic management approach. This study explores the implementation of PROs as an intervention component within a precision medicine program, with a focus on identifying facilitating factors and barriers from the perspectives of health care providers (HCPs) and patients with stage IV non-small-cell lung cancer (NSCLC). Semi-structured individual interviews were conducted with HCPs and NSCLC patients over two rounds in 2023 and 2024, respectively. Verbatim transcripts were analyzed using qualitative content analysis. The framework of Grol and Wensing was employed, which divides healthcare into six dimensions. The structured documentation of symptoms and quality of life constitutes a benefit in that it enables intervention by the treating physician. From the perspective of HCPs, incorporating PROs into daily clinical practice was associated with considerable organizational challenges and the need for logins into an additional system to access the results. This required a substantial investment of time and personnel, which resulted in a lack of acceptance. The predominant motivation of patients who participated in the PRO questionnaires was a desire to contribute to scientific research. In general, the regular administration of the questionnaire has proven unfeasible for the NSCLC cohort, given the high disease burden often experienced in stage IV. Despite implementation challenges, PROs can improve symptom monitoring, communication, and patient-centered care in advanced NSCLC when key barriers are addressed.
Clinicians frequently encounter patients in the hospital with mild-to-moderate COVID-19 who are at high risk for disease progression. Antiviral drugs reduce the rate of progression to severe COVID-19 when given to these patients within 5-7 days of symptom onset. To look at the utilization of antiviral medications in hospitalized patients with mild-to-moderate COVID-19, a detailed chart review was conducted of 500 randomly selected patients from the Charleston Area Medical Center COVID-19 Registry. We identified 124 patients with mild-to-moderate COVID-19 who were eligible for antiviral treatment. Only 41 of the 124 patients (33.1 %) received antiviral treatment. Providers listed mild symptoms as the most common reason (74.7 %) that antiviral treatment was not started. These findings show that antiviral medications are underutilized in treating high-risk hospitalized patients with mild-to-moderate COVID-19 to prevent disease progression.
To explore the lived experiences of children with type 1 diabetes (T1D) and their caregivers in Armenia, a post-Soviet country, and to identify system-level barriers to care from the community perspective. Qualitative study using a phenomenological design with inductive thematic analysis. Muratsan Hospital Complex, the primary national referral centre for paediatric endocrinology, Yerevan, Armenia. 12 children aged 13-17 years with T1D and their caregivers, recruited through purposive sampling across 7 of Armenia's 10 administrative regions. Five themes emerged from the data: (1) barriers to care, (2) quality of care, (3) perceived control of T1D, (4) knowledge of T1D and (5) government and non-governmental organisation (NGO) support. Participants described unreliable government-supplied glucose strips, geographical barriers rooted in the centralisation of specialist care in the capital, abrupt withdrawal of state support at age 18, reliance on the KATIL NGO to fill gaps in both clinical and psychosocial support and pervasive stigma encountered across family, school and clinical settings. Children with T1D in Armenia navigate a post-Soviet health system where provisions exist but remain fragmented, limited by centralised care, geographical barriers and variable support. This unique context shapes the relationship and expectations patients have of the healthcare system. Community perspectives are indispensable in these settings, surfacing system-level gaps that conventional data cannot capture. These findings have relevance for other health systems navigating similar structural transitions.
Hospital global budgets gained attention as a strategy to constrain costs and improve outcomes. The Maryland all-payer model (APM), initiated in 2014 as a global budget revenue model, is an example of full-risk payment reform; yet frontline surgeon perspectives on the implementation and impact of this APM have not been evaluated. To examine surgeon experiences working under Maryland's APM. This qualitative study used a convergent mixed-methods design to assess survey responses of surgeon experiences and semistructured interviews between June 15 and November 25, 2024. Maryland surgeons were recruited via purposive and snowball sampling for surveys from academic and community surgical practices. A nested sample of respondents was selected for qualitative interviews using maximum variation sampling. The primary outcome was surgeon-reported experiences with Maryland's APM. Surveys and interview guides were designed using the Consolidated Framework for Implementation Research (CFIR) to assess awareness, communication, institutional engagement, changes in practice, and perceived effects on care delivery associated with the APM. Survey responses were summarized, and interview data were thematically analyzed and integrated using CFIR-guided joint displays. Among 121 identified surgeons, 103 responded to the survey (67 [65.0%] male; practicing a mean [SD] of 16.4 [12.7] years), and 88 (85.4%) reported awareness of the APM. Of these 88 surgeons, a minority (35 [38.8%]) recalled information being distributed by their institution, and 41 (46.6%) reported receiving information from peers. Whereas 52 surgeons (59.1%) agreed that complex care had become more centralized, fewer believed that the model improved referral management (15 [17.0%] strongly agreed or agreed) or reduced preventable hospital use (16 [18.2%] strongly agreed or agreed). Most surgeons stated that the model changed the way they practiced at least slightly (56 [63.6%]). In qualitative interviews (n = 25), surgeons described surface-level understanding of the model and limited institutional communication, relying on peer discussions to interpret its implications. Many surgeons expressed confusion about performance expectations and frustration with the lack of feedback on quality metrics. They also noted that financial incentives shifted complex care to tertiary centers, contributing to resource strain. In this mixed-methods study of surgeons' experiences, surgeons reported high awareness of Maryland's APM, but integrated findings revealed limited operational understanding, inconsistent institutional communication, and indirect effects on practice. Implementing alternative payment models may require more deliberate engagement of clinician stakeholders, clearer communication strategies, and alignment of clinical incentives.
Actinomycosis is a rare, chronic, suppurative bacterial infection caused by Actinomyces spp with an incidence of 0.3 cases per million people annually. The cervicofacial area is the most common site of infection and accounts for approximately 50 percent of all cases. Most cases of cervicofacial actinomycosis are odontogenic in origin. Hemoptysis in the setting of actinomycosis commonly occurs from pulmonary involvement. Hemoptysis secondary to isolated cervicofacial actinomycosis has seldom been documented in literature. We hereby present a case of cervicofacial actinomycosis presenting with hemoptysis likely secondary to an oro-cervical fistula. We aim to highlight the challenges in diagnosis of this relatively rare clinical entity and the potential for life threatening complications if not detected and managed appropriately.
In response to the growing demand for prehospital care in the Central Denmark Region, a single responder ambulance, the Prehospital Visitation Unit (PVU), was introduced in early 2022. Staffed by a single paramedic, the PVU focuses on completing patient treatment on-site and/or facilitating access to appropriate healthcare services. Despite the increasing implementation of non-conveyance initiatives, little is known about patients' experiences of receiving emergency medical care in such settings. This qualitative study aimed to explore patients' expectations when calling for emergency help and their experiences with encountering the PVU in response to their need for help. The study was conducted in two stages of fieldwork: preliminary and main. Participant observation and semi-structured interviews were utilized throughout. The preliminary fieldwork took place between 1 June and 31 August 2022, and the main fieldwork between 1 February and 30 March 2023. In total, the researchers observed 12 PVU shifts, documenting patient-paramedic encounters through fieldnotes. Additionally, 22 patients completed a follow-up telephone interview. Interview transcripts and fieldnotes were analyzed using a two-cycle coding approach. Overall, patients expressed satisfaction with the PVU and appreciated receiving treatment on-site rather than being transported to the hospital. When asked about their expectations after calling the Emergency Medical Services (EMS), patients consistently emphasized that they "just needed help". They were unconcerned about which type of EMS resource was dispatched or how many staff arrived. The PVU was perceived as less dramatic due to its smaller vehicle and single-paramedic operation. The paramedic's calm attitude, clear communication, and use of eye contact contributed to a reassuring atmosphere that put patients at ease. This study highlights patient satisfaction with the PVU as an EMS response, emphasizing their need for help and the benefits of on-site treatment. It contributes to the scarce literature on patient perspectives regarding non-conveyance, showing how the PVU meets patient expectations, creates a calm atmosphere, and fosters a sense of safety.
Transitions of care (ToC) programs are important for patient safety, but their implementation and success remain highly variable across US hospitals, particularly for patients with multimorbidity and health-related social needs (HRSNs). Hospitalists, as key decision-makers at discharge, encounter firsthand the factors that hinder the success of ToC programs. To explore hospitalists' perspectives on successes, shortcomings, and implementation barriers in ToC programs, particularly during transitions from hospital to community settings. Rapid qualitative study featuring virtual focus groups with participants from the Hospital Medicine Reengineering Network (HOMERuN). Data were analyzed using a mixed inductive-deductive framework to identify key themes. Twenty-two individuals from 19 different organizations participated in focus groups. None of the organizations offered comprehensive ToC programs to all patients. Four major themes emerged: (1) Diagnosis-specific ToC programs are effective but contribute to care fragmentation, particularly for patients with multimorbidity; (2) postdischarge follow-up is hindered by limited appointment availability, insurance barriers, and geographic challenges; (3) ToC programs often fail to address patient preferences, HRSNs, and health literacy, and lack adequate resources and leadership support; (4) successful programs require institutional commitment, dedicated funding, interprofessional collaboration, and community engagement. Participants emphasized the need to prioritize patient-centered care over financial return on investment. Current ToC programs are fragmented, undermining safe and equitable transitions. Addressing HRSNs, fostering leadership support, and prioritizing patient-centered care over short-term financial metrics are essential for improving ToC outcomes.
Drug use disorders (DUDs) are emerging global public health challenges. Here we investigated the global and regional estimates of the prevalence and burden of DUDs, including amphetamine, cannabis, cocaine and opioid use disorders, from 1990 to 2023 for 204 countries and territories by using the Global Burden of Disease Study 2023. Overall, trends in global age-standardized disability-adjusted life-years of DUDs increased from 169.3 (95% uncertainty interval (95% UI), 134.4-203.9) per 100,000 people in 1990 to 212.0 (95% UI, 179.2-245.6) in 2023. In 2023, both prevalence and burden of DUDs were higher in high-income countries, particularly in the USA. The most prevalent DUDs in 2023 were cannabis use disorder (age-standardized prevalence, 270.8 (95% UI, 201.7-350.0) per 100,000 people) and opioid use disorder (205.9 (95% UI, 178.7-235.0)). Particularly, opioid use disorder showed a nearly twofold increase in prevalence and burden between 1990 and 2023. In 2023, compared with countries where cannabis use was illegal, countries permitting both recreational and medical cannabis use had higher prevalence rates for all types of DUDs. Proactive and effective policies are essential to mitigate the increasing global burden of DUDs.
Intussusception is predominantly a pediatric condition, with only about 5 % of all intussusception cases occurring in adults with primary intestinal lymphomas comprising 1 %-4 % of gastrointestinal malignancies, 90 % of which are B-cell non-Hodgkin lymphomas (NHL). Diffuse large B-cell lymphoma (DLBCL), the most common subtype of NHL, often leads to intussusception without classical B symptoms. We present the case of a 33-year-old male with ileocolonic intussusception caused by a 4.8 × 5.3 × 5.5 cm enhancing mass. Histopathology and FISH confirmed DLBCL without MYC, BCL2, or BCL6 rearrangements, ruling out double- or triple-hit lymphoma. Following a right ileo-colectomy, R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy was initiated. This case underscores the role of malignancy in intussusception and highlights the importance of timely diagnosis and management.