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In the last 2 decades, transcatheter aortic valve replacement (TAVR) has become widely adopted for the treatment of aortic valve stenosis, and prosthetic valve embolization (PVE) is one of the rarely reported, but often catastrophic, complications of this procedure. The authors performed an updated systematic review of contemporary studies to determine the prevalence of post-TAVR PVE and its associated risk factors. A systematic search was conducted in multiple databases for all relevant published studies from 2014 to August 2024. Studies reporting on embolization were included. Data extracted encompassed participants' characteristics, study characteristics, and clinical outcomes. Pooled event rates were calculated using the random effects method. In the final analysis, 34 studies reported 501 cases of device embolization, of which 50% were male with a mean age of 80.7 ± 3.16 years while the other 50% were female. The rate of PVE was 1.4%. About 80% of the embolization occurred in the intraprocedural period, with 61% of the embolized valves requiring surgical treatment. The prevalence of embolization across included studies was 1.4%, with most embolization occurring during the procedure. The chance of mortality is significantly heightened at about 18% to 20% at 30 days and ~30% at 1 year in some series, compared with much lower baseline rates for uncomplicated TAVR. Prosthetic valve embolization complicates TAVR procedures, increasing procedural complexity, with over 50% of instances resulting in conversion to surgical intervention. Given that this complication is rare (~1%), the overall risk is low in the general TAVR population, but for the individual, it is serious and warrants aggressive management.
Multiple publications have shown that there is gender-based discrimination in surgery, aimed against surgeons who are women. The authors theorize that it was not due to a difference in clinical competence, but due to implicit bias: a subconscious prejudice that traditionally assigned women to homemaker roles. The authors designed this study to determine whether gender discrimination was due to implicit bias or a quantifiable difference in clinical competence. This questionnaire study investigated prevailing attitudes among a professional association of surgeons in the Anglophone Caribbean. The authors collected data on gender discrimination and 4 parameters as proxies for clinical competence: judgment, thoroughness, surgical skill, and task completion. The SPSS version 20 was used to perform statistical analyses. A total of 140 questionnaires were distributed and 95 (68%) respondents observed gender discrimination in the workplace, with surgeons who are women significantly more likely to be victims of discrimination (64.2% vs 4.2%; z -8.7165; P < .0001). There was no difference between genders in clinical judgment nor surgical skill. There was a significant difference in thoroughness (47.4% vs 2.1%; P < .0001) and task completion (60% vs 24.2%; P < .0001), favoring surgeons who are women. Gender discrimination is still prevalent in surgical disciplines as the second quarter of the 21st century begins. The authors have demonstrated that surgeons who are women are substantially more likely to be the victims, likely due to implicit gender bias. The surgical community must address this urgently, because impeding full participation by women creates the chance for undermining the expansion of the workforce needed for the next generations' surgical care.
Chronic kidney disease (CKD) affected > 35 million US adults in 2023. Effective therapies exist to reduce CKD progression and risk of cardiovascular events. However, whether population-level management strategies are effective is not known. The authors evaluated a program that proactively identified and referred high-risk patients to a structured CKD management approach aimed at improving guideline-direct care. Within a large, integrated health care delivery system, the authors enrolled adults with high-risk CKD identified from electronic health records between June 2021 and March 2022 who were not receiving nephrology care into a structured CKD management program based on a multidisciplinary, nephrologist-led model of care. These patients were compared to a matched cohort of high-risk patients with CKD receiving usual care. The authors evaluated feasibility and differences in targeted process measures over a 3-month follow-up period. Among 120 eligible patients with CKD enrolled in the program and 120 matched patients with CKD receiving usual care, mean (standard deviation) age was 73.9 (8.4) years, 57.8% were women, and demographic characteristics and comorbidity burden were well matched. Despite the COVID-19 pandemic, implementing the structured CKD management program was feasible. During the 3-month follow-up period, those enrolled in the CKD management program experienced a higher rate of estimated glomerular filtration (58% vs 43%, P = .02) and urinary protein (38% vs 11%, P < .0001) testing. Proactive referral to structured CKD management was feasible and led to increased short-term surveillance of kidney function. Future studies should assess whether engagement at earlier stages of CKD and longer systematic care and follow-up can improve outcomes and inform broader implementation of population-level CKD management strategies.
Rapid initiation of antiretroviral therapy (Rapid ART) is a key strategy of the Ending the HIV Epidemic (EHE) initiative. The Baylor College of Medicine Extension for Community Healthcare Outcomes (ECHO) Facilitating Antiretroviral Start Earlier (BE FASTER) program was developed to address this call-to-action. The program uses the ProjectECHO tele-mentoring model as an implementation tool in Harris County, a priority EHE jurisdiction. The authors present results on the acceptability and feasibility of the BE FASTER program. Multidisciplinary health professionals from 5 Ryan White Part A funded agencies formed the community of practice. The BE FASTER program included 9 monthly virtual sessions, consisting of a brief didactic presentation and case-based discussions focused on Rapid ART implementation. Surveys to measure cross-agency collaboration, sense of professional support, organization efficacy, and self-knowledge and skills were administered at baseline and 9 months. Data were collected on the number of clients initiated on Rapid ART through EHE funding over the course of BE FASTER. Overall, 64 unique participants attended the 9 ECHO sessions, with an average attendance of 26 participants. Self-knowledge and skills significantly increased at 9 months (3.63 vs 3.96, P < .01). Satisfaction scores were high; 80% of participants were "mostly" or "completely" satisfied with the program, and 97% of participants would "probably" or "definitely" recommend the program. The number of clients started on Rapid ART through EHE funding since BE FASTER started has increased each year of the program. The BE FASTER community of practice is an acceptable and feasible intervention to bring organizations together to develop, disseminate, and adopt vital initiatives for Rapid ART.
Trauma-informed care (TIC) provides a framework for understanding and mitigating trauma's impact on health. Integrating TIC principles into medical school education equips physicians with the skills necessary for delivering compassionate, patient-centered care. A survey regarding experiences with TIC education was emailed to medical students and faculty at the University of Oklahoma College of Medicine. Qualitative and standard quantitative analysis of the results was performed. A significant majority of faculty (83.7%) and students (92.5%) recognized the relevance of TIC to clinical practice. However, only 37.0% of faculty reported incorporating TIC into their teaching. Despite its acknowledged importance, only 20.4% of students felt satisfied with how TIC was taught. On a Likert scale of 1-5, students reported a comfort level of 1-2 for trauma-informed screenings (31.5%) and physical examinations (62.9%). Proposed solutions to increase TIC education included the implementation of longitudinal curricula, workshops, and conversations about trauma when interacting with patients. TIC is perceived as relevant to medical education and practice among students and faculty. However, its integration into the undergraduate medical education curriculum is sporadic. Although certain courses incorporate TIC, a cohesive teaching approach throughout the curriculum is lacking. There is uncertainty among faculty regarding the definition of TIC and what aspects may be lacking in the curriculum, highlighting a gap in knowledge and application. The intermittent teaching of TIC affects students' ability to fully understand the impact of trauma in the clinical setting. The authors' results supported the integration of a more comprehensive TIC education in undergraduate medical curricula.
Disasters, including the recent COVID-19 pandemic, have disproportionately impacted nursing homes (NHs). NH residents experienced higher mortality during the pandemic, but not all NH were affected equally. Appalachia has a history of reduced health compared to the general United States. Therefore, this study is focused on NHs in Appalachia during the COVID-19 pandemic. This study aimed to investigate how the neighborhood and NH characteristics are associated with mortality in Appalachian NHs during the COVID-19 pandemic. Using publicly available datasets, including NH, patient, and county-level characteristics, the authors' investigated how the these factors impacted COVID-19 death, COVID-19 death rate, and total NH deaths by adopting negative binomial regression outcomes and multiple linear regression models. A total of 1259 NHs in Appalachia were included in the analysis. Deaths from COVID-19 were positively associated with the number of NH beds, share of White residents, and resident age. Centers for Medicare & Medicaid Services 5-star quality rating was negatively associated with COVID-19 deaths. On the other hand, although number of beds, acuity index, share of White residents, average age, and share of White residents in the community were positively associated with total deaths, lower county education levels and county income were negatively associated with total deaths. NH and county characteristics associated with NH deaths varied from prior literature that included the general United States. Policymakers and NH leaders responsible for NHs in Appalachia should be sensitive to regional differences when making decisions and resource allocations.
Opioids are highly effective for pain management but carry risks. Naloxone quickly reverses opioid overdoses by blocking opioid receptors in the brain. Despite its effectiveness, naloxone remains underutilized. Kaiser Permanente created the Interregional Pharmacy Opioid Use Improvement Group to support safe opioid prescribing and increase appropriate naloxone prescribing. This retrospective study included Kaiser Permanente Georgia members who were 18 years or older and filling chronic opioid therapy of ≥ 50 morphine milligram equivalents (MME) averaged over the previous 90 days. The primary objective was to compare the number of patients who filled a naloxone prescription within the last 24 months as of March 31, 2023 (preintervention) vs as of December 31, 2023 (postintervention). The secondary outcome was to compare the naloxone fill rates based on intervention type. As of March 31, 2023, 122 out of 399 patients (30.6%) had filled naloxone prescriptions compared to 241 out of 356 patients (67.7%) as of December 31, 2023 (30.6% vs 67.7%; P < .0001). Out of 56 patients who received only a secure email, 42 (75%) filled their prescriptions. For patients who spoke directly with a pharmacist or technician, 91 (91%) filled their prescriptions. Among patients who were not directly reached and received a voicemail, 15 (41%) filled their prescriptions. Pharmacy-led interventions, particularly telephone outreach, were effective at improving naloxone fill rates in patients on chronic opioid therapy of ≥ 50 morphine milligram equivalents per day. Voicemails had a lower fill rate, highlighting the importance of direct interaction in improving patient outcomes.
In 2015, a national working group developed and published a conceptual framework for trauma-informed primary care (Machtinger et al., 2015Machtinger E.L. Cuca Y.P. Khanna N. Rose C.D. Kimberg L.S. From treatment to healing: the promise of trauma-informed primary care.Womens Health Issues. 2015; 25: 193-197Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar). Since that publication, there has been increasing recognition that childhood and adult trauma underlie and perpetuate many physical and behavioral health conditions seen in health care settings and that addressing trauma could fundamentally improve the experience and efficacy of care for both patients and providers. A number of high-level efforts are currently under way to translate trauma-informed principles and frameworks into practical guidance for health care providers and practices (e.g., clinics and offices), including comprehensive endeavors by the Substance Abuse and Mental Health Services Administration and the National Council for Behavioral Health. The original 2015 conceptual framework focused on adult primary care. Since that time, it has become clear that the model applies equally well to a wide variety of other adult health care specialties in which trauma is known to affect the experiences and outcomes of care. These include obstetrics and gynecology, rheumatology, neurology, infectious disease, geriatrics, palliative care, and many other medical and surgical specialties. As such, the framework is now referred to as trauma-informed health care (Figure 1). Trauma-informed health care has five core components: a foundation grounded in trauma-informed principles and a team approach; an environment that is calm, safe, and empowering; education about the impacts of current and past trauma on health; and inquiry about and response to recent and past trauma that includes onsite or community-based resources and treatments. A more detailed description of each of these components can be found in the original article (Machtinger et al., 2015Machtinger E.L. Cuca Y.P. Khanna N. Rose C.D. Kimberg L.S. From treatment to healing: the promise of trauma-informed primary care.Womens Health Issues. 2015; 25: 193-197Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar). Herein, we provide guidance for adult health care providers and practices about how to inquire about and respond to recent and past trauma as a way of more effectively addressing many common health problems. Although these two components of trauma-informed health care are the focus of this article, we also recommend that providers and practices take certain key preparatory steps that are necessary to lay the foundation for trauma inquiry and response. First, recognize that trauma is common. Many people have experienced childhood and/or adult trauma that has a lasting impact on their mental and physical health (Black et al., 2011Black M.C. Basile K.C. Breiding M.J. Smith S.G. Walters M.L. Merrick M.T. Stevens M.R. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta2011Google Scholar, Felitti et al., 1998Felitti V.J. Anda R.F. Nordenberg D. Williamson D.F. Spitz A.M. Edwards V. Marks J.S. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study.American Journal of Preventive Medicine. 1998; 14: 245-258Abstract Full Text Full Text PDF PubMed Scopus (9697) Google Scholar). Understanding this impact helps to clarify why some conditions remain refractory to traditional therapies and why some patients seem to be hard to engage, defensive, demanding, or “on edge.” This understanding informs a fundamental shift in the way each person on the health care team (providers and staff) thinks about patients, from “What is wrong with you?” to “What has happened to you?” Ultimately, this trauma-informed perspective helps the health care team to sustain a compassionate and patient-centered approach and develop more satisfying relationships and more effective treatment plans with patients. Next, adopt trauma-informed principles. Trauma can damage a person's sense of safety and trust and can adversely affect relationships. To provide a healing environment for both patients and the health care team, integrate trauma-informed principles into your practice (safety, trustworthiness, collaboration, peer support, empowerment, and cultural humility and responsiveness; Reyes, 2017Reyes L. Trauma-Informed Systems (TIS) Healing Ourselves, Our Communities and Our City: Program overview. Department of Public Health, San Francisco2017http://traumatransformed.org/wp-content/uploads/TIS-Program-Overview-11-15-17.pdfGoogle Scholar, Substance Abuse and Mental Health Services Administration (SAMHSA), 2014Substance Abuse and Mental Health Services Administration SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD2014https://store.samhsa.gov/system/files/sma14-4884.pdfGoogle Scholar). Then, offer education and resources for patients, staff, and providers. Educate all patients, staff, and providers about the connections between trauma, health, and health-related behaviors. Understand that patients may not disclose trauma for many reasons, including shame and fear. Recognize that health care staff and providers may also have suffered traumatic life experiences and can experience vicarious trauma. Supportive responses for staff and providers include regular interdisciplinary team meetings to decrease isolation, supporting opportunities for self-care, and facilitating access to employee support services available in many institutions. Thereafter, establish referral processes for patients wanting further service and/or treatment. Having referral processes in place increases provider comfort when asking about trauma and facilitates referrals to onsite or community-based services that are trauma-informed and that match the patient's needs, desires, and readiness. Integrating behavioral health providers into primary care and medical subspecialties greatly facilitates this process. Establishing referrals to address other social determinants of health such as housing and food insecurity can also contribute to reducing the incidence and adverse impacts of trauma. Providers and staff can embrace techniques that greatly facilitate inquiry about and response to trauma. We suggest using the “4 Cs” (Kimberg, 2016Kimberg L. Trauma and trauma-informed care.in: King T.E. Wheeler M.B. The medical management of vulnerable and underserved patients: Principles, practice and populations. McGraw-Hill Professional, Upper Saddle River, NJ2016Google Scholar). Your ability to stay calm and grounded when caring for a patient who has experienced trauma is emotionally regulating for the patient and can make your visits more productive and healing. You do not need to elicit a detailed trauma history to be compassionate and offer help. Providing information, resources, and referrals to address a patient's trauma facilitates an interaction that is emotionally manageable for you and the patient. Emphasize good self-care and compassion for both the patient and yourself. Guilt and shame are very common feelings for survivors of interpersonal violence. A nonjudgmental attitude is extremely helpful. Destigmatize the adverse consequences of trauma such as substance use, overeating, and depression. Emphasize resilience and strengths. Solicit and incorporate the skills and strategies the patient has used in the past to overcome difficulties. After these preparatory steps, providers and practices can move toward a more consistent approach to inquiring and responding to current and past trauma. Trauma inquiry is guided by a hierarchy of needs in which immediate safety is the top priority. As such, it is essential that practices are prepared to address current abuse or violence, such as intimate partner violence (IPV). IPV is a particularly common form of violence that has a strong evidence base for effective screening and response (U.S. Preventive Services Task Force, 2018U.S. Preventive Services Task Force Final update summary: intimate Partner violence and abuse of elderly and vulnerable adults: Screening.2018https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1www.uspreventiveservicestaskforce.orgGoogle Scholar). Whether inquiring about IPV as part of history taking or with standardized screening tools, it should be done in private. If there are language barriers, professional (not family) interpreters should always be used. Some settings may choose to emphasize universal education, in which providers use informational materials to educate patients about IPV, provide resources, and facilitate discussion before direct inquiry. An appropriate response when a patient discloses IPV or another form of recent violence is to affirm that she or he does not deserve to be treated that way; express concern for the patient's safety and that there are many helpful resources; and offer a warm handoff to an onsite social worker or to a local or national domestic violence agency to provide ongoing support services, preferably while the patient is still on site. A domestic violence hotline (e.g., National Domestic Violence Hotline 1-800-799-SAFE (7233)) accessed by telephone from the clinic can provide emotional support, do safety planning, assess for lethality risk, and provide practical resources such as shelter or legal assistance. Many resources and tools are available to help clinics provide or link to more robust IPV services (http://ipvhealth.org/). There are fewer evidence-based health care protocols for how to inquire about past trauma. Herein, we describe four general approaches (Figure 2). All patients can be approached using a “trauma lens” that assumes that difficult life experiences may have contributed to current illnesses and coping behaviors. Universal education can be provided about the connection between trauma and physical and emotional health. Regardless of whether or not a patient chooses to disclose their trauma history, referrals can be offered to onsite or community-based interventions that address experiences and consequences of past trauma. Another promising way to inquire about trauma that does not require patients to describe details of past traumatic experiences is to screen for symptoms of common conditions that are highly correlated with traumatic experiences, such as anxiety, post-traumatic stress disorder, depression and suicidality, substance use disorder, chronic pain, and morbid obesity (U.S. Department of Veterans Affairs National Center for PTSD, 2018U.S. Department of Veterans Affairs National Center for PTSD Co-occurring conditions.2018https://www.ptsd.va.gov/professional/treat/cooccurring/index.aspDate accessed: September 30, 2018Google Scholar). These conditions are often markers for past trauma and are themselves often highly stigmatized. A patient experiencing any of these conditions would benefit greatly from having them addressed in a nonjudgmental, compassionate, trauma-informed manner. Treatments for these conditions are most effective when onsite or community-based services are trauma-informed and offer evidence-based trauma-specific interventions. In contrast with structured tools, open-ended questions included in routine history taking allow patients to disclose any form of trauma they feel is relevant to their well-being. For example, an open-ended script can be: “Difficult life experiences, like growing up in a family where you were hurt, or where there was mental illness or drug/alcohol issues, or witnessing violence, can affect our health. Do you feel like any of your past experiences affect your physical or emotional health?” [If yes] “I am so sorry that happened to you. Past traumas can sometimes continue to affect our health. If you would like, we can talk more about services that are available that can help.” It is important for providers to know that there are many different types of traumatic experiences that may have had a significant impact on patients’ health, including childhood and adult physical and sexual abuse; bullying; community violence; war; serious accidents or illnesses; structural violence such as racism, sexism, xenophobia, homophobia, and transphobia; and experiences in the foster care, criminal justice, or immigration systems. If a structured screening tool or process is used, carefully consider when, how, and by whom it will be administered, as well as who will have access to the information. Some clinics use a previsit screening tool administered via electronic tablet, paper, or small wipe-off board. In other settings, nonclinical staff administer the tool, or medical providers conduct the standardized screening in the examination room. Regardless of what tool is used and how it is administered, it is essential that the patient be able to discuss their responses with the provider in private. Multiple validated scales exist to screen for past trauma (https://www.ptsd.va.gov/professional/assessment/te-measures/index.asp). One such tool is the Adverse Childhood Experiences (ACE) Questionnaire, which was designed as a research instrument to measure the rate of childhood trauma in a clinic population. The clinical benefits of screening for ACEs in adult primary care are being actively investigated (link to more ACEs information: https://acestoohigh.com/aces-101/). The choice of approach to inquiring about past trauma depends on the resources, expertise, and patient population of individual providers and practices. It is important to note that for patients who have experienced severe and/or cumulative trauma (i.e., complex trauma) and are experiencing negative physical or emotional health consequences, it will be helpful for the provider or behavioral health clinician to know the general nature of their traumatic experiences (e.g., childhood sexual abuse, abusive parents with serious mental illness, combat-related exposure) to make the most effective referral to trauma-specific treatments. Disclosures of past trauma do not typically require detailed discussion or urgent intervention. Rather, responses to such disclosures are often best limited to a statement of empathy, an offer of available referrals to overcome the impacts of trauma, and an opportunity to follow-up with you. Providers should first acknowledge the patient's disclosure with a simple statement of nonjudgmental compassion like, “I am sorry this happened to you. Thank you for sharing this with me. This information can help me understand how best to care for you.” This can be followed up with a question like “Past traumas can sometimes continue to affect our lives and health. Do you feel like this experience continues to affect your health or well-being?” Understanding a patient's past trauma can explain how coping techniques like substance use or disordered eating may have been adaptive in the past (Felitti et al., 2010Felitti V.J. Jakstis K. Pepper V. Ray A. Obesity: Problem, solution, or both?.Permanente Journal. 2010; 14: 24-30Crossref PubMed Google Scholar), but are currently causing health problems. This understanding can often facilitate a more effective treatment plan. For example, treatments for substance use disorder have been shown to be significantly more effective if co-occurring trauma and/or posttraumatic stress disorder are addressed as part of the treatment (Dass-Brailsford and Amie, 2010Dass-Brailsford P.M. Amie C. Psychological Trauma and Substance Abuse: The need for an integrated approach.Trauma, Violence, & Abuse. 2010; 11: 202-213Crossref PubMed Scopus (38) Google Scholar). Using a harm reduction framework can be a good first step. This can include a brief conversation about how a substance-using patient can stay safe while still using. “You mentioned that alcohol makes you feel calm when you are very stressed and that you have a goal to stop drinking, but are not ready to now. So let's talk about how you can stay safe when you do drink. What ideas do you have? Have you considered limiting the number of drinks you drink each time you drink?” Depending on the desires and readiness of the patient, providers may offer referrals for further evaluation or treatment. This could include a referral to onsite behavioral health providers or community-based programs that are trauma-informed and offer trauma-specific therapies. Patients and providers can find local mental health and substance abuse services at the Substance Abuse and Mental Health Services Administration website or National Help Line (www.samhsa.gov/find-help/national-helpline or National Helpline 1-800-662-HELP (4357)). There are many evidence-based trauma-specific techniques and mental health interventions to help patients heal from the impacts of past trauma and cope more healthfully and safely with persistent symptoms and persistent traumas, such as racism or xenophobia. Medical providers are not typically resourced or trained to lead these interventions. Nonetheless, they have a crucial role to play in linking patients to trauma-informed treatments in the community or to onsite psychosocial staff members who are skilled in providing them. Most important, providers can communicate hope to patients that it is possible to heal from even the deepest wounds of trauma and that it is possible to gradually adopt healthier coping strategies. Learning more about trauma-specific interventions can help providers to identify what may be most useful for each patient. Trauma-specific interventions include 1) individual and/or group therapies that help patients to manage trauma symptoms, process traumatic experiences, and reduce isolation, 2) trauma-informed somatic interventions like mindfulness, yoga, somatic experiencing, and acupuncture, and 3) medicines to reduce posttraumatic symptoms like insomnia, anxiety, and depression. Often, it is a combination of such interventions that leads to genuine healing. It is important to recognize that helping an adult to heal from trauma can benefit both the patient and their families and children, helping to disrupt intergenerational cycles of trauma. Practical tips about how adults can help children to overcome the impacts of trauma can be found here: https://changingmindsnow.org/. Although some patients may not feel ready to engage in deeper trauma-specific interventions, there are many approaches that do not involve directly processing trauma. These trauma-specific services can start the healing process by helping patients to connect with others and develop healthier coping skills. These services include drop-in peer support groups, trauma-informed behavioral health counseling and psychiatry, group therapy that addresses trauma and substance use (e.g., Seeking Safety; Najavits et al., 1998Najavits L.M. Weiss R.D. Shaw S.R. Muenz L.R. Seeking safety: Outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence.Journal of Traumatic Stress. 1998; 11: 437-456Crossref PubMed Scopus (350) Google Scholar), Wellness Recovery Action Plan groups (Copeland, 2002Copeland M.E. Wellness recovery action plan: A system for monitoring, reducing and eliminating uncomfortable or dangerous physical symptoms and emotional feelings.Occupational Therapy in Mental Health. 2002; 17: 127-150Crossref Scopus (68) Google Scholar), mindfulness-based stress reduction, trauma-informed somatic therapies (e.g., yoga), and various forms of expressive and art-based therapies (Machtinger et al., 2015Machtinger E.L. Lavin S.M. Hilliard S. Jones R. Haberer J.E. K. C. An expressive therapy group disclosure for women with social support, and the safety and of a of the of in 2015; PubMed Scopus Google Scholar). Providers can also support patients who do not any trauma-specific referrals healing and caring for people and and other practices in which they find and Providers and clinics that adopt a trauma-informed inquire about trauma, and provide to trauma-specific services will offer new to support more satisfying and effective relationships for both patients and providers. toward trauma-informed health care has the to the experience and efficacy of health care from treatment to genuine healing for both patients and providers.
Annual variations in the population-based incidence of acute urticaria (AU) and chronic urticaria (CU) are poorly understood, specifically in relationship to non-COVID-19 viral respiratory infections (NCVRIs). To determine the annual incidence of AU and CU, health care utilization for NCVRIs and demographic associations across 3 periods: pre-COVID-19, COVID-19 without vaccinations, and COVID-19 with vaccinations. The researchers reviewed the medical records from 2017 to 2022 of all Kaiser Permanente Southern California Health Plan members with and without urticaria leading to health care utilization. There was a total of 7,404,343 unique individuals with any Kaiser Permanente Southern California Health Plan coverage between 2017 and 2022, contributing to 26,852,884 patient-years of follow-up. The annual incidence of AU per 100,000 patient-years was 1543 in 2017, 1533 in 2018, 1586 in 2019, 1194 in 2020, 1345 in 2021, and 1434 in 2022. The annual incidence of CU per 100,000 patient-years was 101 in 2017, 113 in 2018, 123 in 2019, 95 in 2020, 113 in 2021, and 129 in 2022. The number of annual health care visits for NCVRIs per 100,000 patient-years was 14,588 in 2017, 13,409 in 2018, 14,843 in 2019, 8671 in 2020, 6507 in 2021, and 11,191 in 2022. There was a significant correlation between NCVRIs and AU (r = 0.82, P = .05) but not between NCVRIs and CU (r = 0.10, P = .86). There was a decrease in AU incidence during the COVID-19 era before and after vaccines. AU may be associated with NCVRIs.
The Mediterranean diet (MD) is a dietary pattern for which the health benefits in prevention of cardiovascular disease, cancer, and metabolic disorders have been well-substantiated. However, emerging clinical literature has shown its promise in reducing risk and disease activity in many autoimmune diseases. This review focuses on literature about components of the MD and their role in modulating inflammatory pathways implicated in autoimmune disease. This review also focuses on literature assessing the MD's associations with clinical outcomes in rheumatoid arthritis (RA), a systemic autoimmune condition primarily affecting one's joints. The core components of the MD (such as whole grains, fish, olive oil, yogurt, cheese, and moderate red wine consumption) have been seen to reduce laboratory and clinical markers of inflammation through a number of mechanisms. Recent population-based cohort studies and randomized clinical trials have been more equivocal in their findings. This suggests that although the MD may have statistically significant impacts on RA risk and symptom severity, these effects are of uncertain clinical significance. This highlights the ongoing need for high-quality clinical research on lifestyle interventions in RA and other autoimmune diseases, along with the continued importance of emphasizing lifestyle-based interventions in the management of chronic disease.
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have traditionally been the treatment for colorectal peritoneal metastasis (CPM). PRODIGE 7, a French multicenter trial, showed no survival difference with the addition of HIPEC to CRS but showed increased morbidity. With substantial differences between US and French HIPEC regimens, validity of PRODIGE 7 in US practice has been questioned with concern that omission of HIPEC will result in undertreatment. Given these controversies, the authors evaluated their experience of CRS with and without HIPEC in patients with CPM to compare morbidity, recurrence patterns, and overall survival (OS). Retrospective cohort study was performed to evaluate patients with CPM undergoing CRS with or without HIPEC within a single health care system. HIPEC regimen was mitomycin-C/90 min. Thirty patients with CPM were identified; 23 underwent CRS-HIPEC, while 7 underwent CRS only. Between groups, there were no differences in age, sex, surgical or systemic treatment history, preoperative carcinoembryonic antigen levels, and time from diagnosis of CPM to surgery. There was no difference in peritoneal cancer index scores, regions affected by CPM, resected organs, and operative time. There was no difference in length of stay, surgical reinterventions, and all 30-day morbidity. There was no difference in 1-year OS. With addition of HIPEC-mitomycin to CRS, patients had longer time to return to regular diet and intensive care unit length of stay, without difference in 1-year OS. CRS with mitomycin-HIPEC can be considered for treatment of CPM without significant morbidity and equivalent short-term oncologic benefits. However, the long-term benefit of HIPEC remains unclear.
Prior studies have reported learning curves as surgeons adopt new technology/techniques. The authors sought to evaluate revision risk following primary total knee arthroplasty (TKA) to assess whether a learning curve was observed as surgeons transitioned to 1) a new implant from the same manufacturer and 2) a new implant from a new manufacturer. Patients ≥ 18 years of age who underwent primary fixed bearing, posterior stabilized, fully cemented TKA with patella resurfacing were identified using a US integrated health care system's total joint replacement registry (2009-2023). The exposure groups were categorized in these groups: baseline implant (reference), first 50 TKA with new implant (≤ 50), second 50 (51-100), third 50 (101-150), and the remainder (> 150). A multiple Cox proportional hazard regression was used to evaluate revision risk with adjustment for confounders. The intra-manufacturer cohort comprised 42,743 TKA. A higher revision risk was observed for the ≤ 50 group compared to the baseline group (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.01-1.86); no other differences were observed after the first 50 TKA (51-100: HR, 0.98; 95% CI, 0.71-1.34; 101-150: HR, 0.95; 95% CI, 0.69-1.32; > 150: HR, 0.99; 95% CI, 0.79-1.34). However, the association was no longer significant after excluding the TKA performed with the Attune fixed bearing tray, which has been associated with a higher risk of revision in the total joint replacement registry. The inter-manufacturer cohort comprised 19,817 TKA. No differences were observed when comparing a new manufacturer to the baseline manufacturer. Surgeons should be cautious for the first several TKA when transitioning to a new implant given the relationship between surgeon and implant on revision risk. Level III.
Prior studies reporting the utilization of anterior cruciate ligament reconstruction (ACLR) was limited to pediatric populations or lacked accounting for the impact of the COVID-19 pandemic. In this study, the authors sought to compare the annual incidence of primary ACLR following the COVID-19 pandemic shutdown to see if utilization has rebounded to pre-pandemic levels. The number of ACLRs performed per year from 2017 through 2023 was identified from the authors' health care system's ACLR interregional registry, and average membership per year was identified from membership records. Incidence rates per 100,000 members were calculated for each year. Poisson regression was used to evaluate year-to-year trends overall and across graft selection, age, and gender. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) are presented. In total, 23,082 ACLRs were performed from 2017 to 2023. Pre-pandemic, annual ACLR incidence increased from 47.0 per 100,000 in 2017 to 50.2 in 2019. During the pandemic (2020), this dropped by 33.9% to 33.2 per 100,000 (IRR, 0.66; 95% CI, 0.63-0.70). Post-pandemic, annual incidence increased from 38.6 to 42.3 per 100,000 from 2021 to 2023, respectively (2020 to 2021: IRR, 1.16; 95% CI, 1.10 -1.23; 2021 to 2022: IRR, 1.11; 95% CI, 1.06-1.16). However, this was still lower than the pre-pandemic incidence. In both genders, patients in the pediatric age groups had the biggest declines during the shutdown (drop off of 57% in the 10- to 14-year-old group and 40% in the 15- to 19-year-old group). The COVID-19 pandemic shutdown of elective orthopedic procedures led to a sharp drop in the numbers of ACLRs performed, and the United States is still in the recovery period.
Inquiring about a patient's adverse childhood experiences (ACEs) and assessment for mental health conditions such as depression and anxiety using trauma-informed care (TIC) approaches may enhance maternity care quality. This study aimed to evaluate the feasibility of a TIC program that integrated mental health and ACE assessment by examining patient and physician perspectives following clinical implementation in a primary care setting. In this exploratory quality improvement project, a maternity care clinic in Calgary, Alberta, implemented a TIC program to assess and address patients' mental health and ACEs between July 2017 and January 2018. Patients' and physicians' perspectives of the program were also attained to understand the feasibility of implementation and use. Patients responded positively to their clinic's use of the TIC program and discussions about their mental health and ACEs with their physicians. They reported feelings of safety, respect, understanding, and receiving informed care. Patients also reported that discussing their ACEs encouraged them to engage in related conversations in their personal lives, seek parenting resources, and expand their knowledge about their ACEs. Physicians reported improved confidence in discussing their patients' ACEs and routine integration of the assessment tools into clinical practice. Integrating ACE and mental health assessment into routine maternity care through the TIC program was associated with positive perceptions from both patients and physicians. Enhanced communication, improved patient-physician relationships, and more optimal patient-centered care resulted. By incorporating these tools into maternity care, health care practitioners can more effectively identify psychosocial risks early, thus supporting improved maternal and fetal health outcomes.
Missed medical appointments lead to adverse health outcomes and financial costs. Adverse childhood experiences (ACEs) are associated with poor health outcomes and may influence health care-seeking behavior in adulthood. This study explored the relationship between ACE scores and missed primary care appointments in a predominantly Black safety-net population. The authors conducted a retrospective cohort study of 307 adult patients in a primary care clinic between January and August of 2022. Patients were recruited using a systematic sampling protocol and completed the 10-item Adverse Childhood Experiences Questionnaire. The primary outcome was no-show behavior, defined as having at least 1 scheduled appointment not attended and not canceled in advance. Logistic regression analyses assessed associations between ACE scores and missed appointments. The sample was 91.9% Black, 44.0% male, with mean age 59.6 years. Average ACE score was 2.3, with 22.5% having ACE scores ≥ 4. Overall, 43.7% of patients had at least 1 no-show visit. ACE scores were not significantly associated with missed appointments (odds ratio, 1.01; 95% confidence interval, 0.89-1.14; P = .94). Medicaid insurance status was the only significant predictor in multivariable analysis (odds ratio, 2.15; 95% confidence interval, 1.07-4.30; P = .03). Contrary to the authors' hypothesis, ACE scores were not associated with appointment adherence. Medicaid insurance status was the strongest predictor of no-show behavior, highlighting the impact of socioeconomic disadvantage on health care engagement. Social determinants such as insurance status may have a stronger influence on appointment adherence than childhood trauma history. Findings underscore the need to address structural barriers in vulnerable populations.
The risk and benefit for patients on dialysis receiving anticoagulation (AC) therapy have not been clearly established. This study aimed to compare the rates of clinically significant thrombotic and bleeding events in patients on dialysis. This is a retrospective cohort study conducted using Kaiser Permanente Northern California's electronic medical record database from 2013 to 2021. Patients over 18 years old on dialysis who were prescribed warfarin or apixaban were included. Patients with mechanical valves were excluded. The outcomes were analyzed using Mann-Whitney tests for continuous variables, χ2 tests for categorical variables, and Kaplan-Meier method for time-to-event analysis. In the study period, 9832 patients were not on AC, and 2088 were taking apixaban or warfarin. The baseline demographics (age, Charlson Comorbidity Index, and sex) were comparable between apixaban and warfarin groups. Among the patients on anticoagulants, 181 were taking apixaban, while 1907 were taking only warfarin. The outcomes 1-3 years within the study period showed that the rates of clinically significant bleeding and thrombosis were comparable in both groups, with the exception of the rate of dialysis access thrombosis being lower in the apixaban group (7% vs 17%, P < .001). In this diverse cohort, apixaban and warfarin showed no clinically significant differences in bleeding rates and lower rate of access thrombosis with apixaban. This study adds to the growing data of AC in the population with end-stage kidney disease, highlighting the need to enroll patients in an adequately powered randomized controlled trial to inform future practice.
Febrile neutropenia is a serious complication in pediatric oncology. Kaiser Permanente Northern California hospitals use varying fever thresholds for admission criteria: the Kaiser Permanente Oakland hospital employs a threshold of 101.5 °F, and Kaiser Permanente Roseville and Kaiser Permanente Santa Clara use lower thresholds. This study aims to assess the potential risks associated with adopting different fever thresholds, including bacteremia, pediatric intensive care unit (PICU) transfer, septic shock, and length of hospital stay. This retrospective cohort study includes Kaiser Permanente Northern California members aged 1 to 18 years with an oncologic diagnosis admitted to 1 of 3 Kaiser Permanente Northern California hospitals with neutropenic fever between 2016 and 2022. Patients admitted with a fever ≥ 101.5 °F (high-temperature group) were compared to those admitted with a fever < 101.5 °F (low-temperature group). The study cohort included 177 patients with a mean age of 8.2 ± 5.4 years, 59.3% male. Of these patients, 70 (39.6%) were in the low-temperature group, and 107 (60.5%) were in the high-temperature group. Overall, 24 (13.6%) patients developed bacteremia, and 24 (13.6%) required PICU transfer. Comparisons between the low- and high-temperature groups showed no statistically significant differences in rates of bacteremia (8.6% vs 16.8%, P = .12), PICU transfer (12.9% vs 14.0%, P = .83), septic shock (2.9% vs 4.7%, P = .71), or length of hospital stay (4.5 [interquartile range 2.5-8.4] vs 4.2 [interquartile range 2.6-8.1] days, P = .98). Future studies with larger sample sizes are needed to validate these findings. Similar studies evaluating outcomes based on admitting temperature can shed light on the most appropriate fever threshold for admission to optimize outcomes for pediatric oncology patients.
The loss of 50,000,000 people during the 1918 influenza pandemic was blamed on war, unsanitary conditions, and lack of vaccines and preparation. Nine decades later, a similar virus (H1N1) killed 285,000 people, and again, the response was that preparation was ineffective, inefficient, and inequitable. Less than a decade later, preparedness for the coronavirus disease 2019 (COVID-19) outbreak revealed the United States was not prepared. This study's objectives were: 1) to develop a deeper understanding of leadership practices that led to successful responses to the COVID-19 pandemic, and 2) to learn about the underlying principles and practices that may help in preparing for the next pandemic. Senior leaders (14/23 or 61%) from across a multisite, multicountry integrated health system were recruited using maximum variation sampling. Individual recorded interviews (averaging 20 minutes) were based on principles of Appreciative Inquiry and critical incident reporting. Iterative consensus coding produced 6 major themes: self- and situation awareness, teamwork, readiness, inspirational leadership, internal communication, and external communication. Beyond individual leadership decisions, organizational culture, shared cognition, and history may play a major role in shaping system-wide responses to catastrophic events like the COVID-19 pandemic. Lack of preparation for dealing with novel events and one-way communication may be risk factors for chaotic and ineffective responses. Senior leaders must balance clinical necessity with humanistic values and purpose. Situation awareness and attention to organizational culture may improve the quality, timeliness, and effectiveness of responses to the next pandemic threat.