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The Canadian Journal of Cardiology Jun 2024Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other... (Review)
Review
Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.
Topics: Humans; Out-of-Hospital Cardiac Arrest; Social Class; Cardiopulmonary Resuscitation; Survival Rate; Emergency Medical Services
PubMed: 38211888
DOI: 10.1016/j.cjca.2024.01.002 -
EClinicalMedicine Jan 2024Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to...
BACKGROUND
Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness.
METHODS
Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975.
FINDINGS
Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity.
INTERPRETATION
Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation.
FUNDING
No specific funding was received.
PubMed: 38204490
DOI: 10.1016/j.eclinm.2023.102380 -
BMC Health Services Research Jan 2024Promoting safe and efficient transitions of care is critical to reducing readmission rates and associated costs and improving the quality of patient care. A growing body...
BACKGROUND
Promoting safe and efficient transitions of care is critical to reducing readmission rates and associated costs and improving the quality of patient care. A growing body of literature suggests that transitional care (TC) programs are effective in improving quality of life and reducing unplanned readmissions for several patient groups. TC programs are highly complex and multidimensional, requiring evidence on how specific practices and system characteristics influence their effectiveness in patient care, readmission reduction and costs.
METHODS
Using a systematic review and a configurational approach, the study examines the role played by system characteristics (size, ownership, professional skills, technology used), the organizational components implemented, analyzing their combinations, and the potential economic impact of TC programs.
RESULTS
The more organizational components are implemented, the greater the likelihood that a TC program will be successful in reducing readmission rates. Not all components have the same effect. The results show that certain components, 'post-discharge symptom monitoring and management' and 'discharge planning', are necessary but not sufficient to achieve the outcome. The results indicate the existence of two different combinations of components that can be considered sufficient for the reduction of readmissions. Furthermore, while system characteristics are underexplored, the study shows different ways of incorporating the skill mix of professionals and their mode of coordination in TC programs. Four organizational models emerge: the health-based monocentric, the social-based monocentric, the multidisciplinary team and the mono-specialist team. The economic impact of the programs is generally positive. Despite an increase in patient management costs, there is an overall reduction in all post-intervention costs, particularly those related to readmissions.
CONCLUSIONS
The results underline the importance of examining in depth the role of system characteristics and organizational factors in facilitating the creation of a successful TC program. The work gives preliminary insights into how to systematize organizational practices and different coordination modes for facilitating decision-makers' choices in TC implementation. While there is evidence that TC programs also have economic benefits, the quality of economic evaluations is relatively low and needs further study.
Topics: Humans; Transitional Care; Aftercare; Quality of Life; Patient Discharge; Cost-Benefit Analysis
PubMed: 38195545
DOI: 10.1186/s12913-023-10461-3 -
BMC Geriatrics Jan 2024After being diagnosed with dementia, patients need a medical professional to empathetically address their fears and get initial questions answered. This scoping review...
INTRODUCTION
After being diagnosed with dementia, patients need a medical professional to empathetically address their fears and get initial questions answered. This scoping review therefore addresses how patients newly diagnosed with dementia are cared for in the general practitioner (GP) setting and how the communication between different healthcare professionals and the GP is handled.
METHODS
The scoping review was conducted based on the PRISMA Extension for Scoping Reviews checklist. After developing a search algorithm, literature searches were performed in PubMed, Scopus, Web of Science, Cochrane Library, PsychInfo, GeroLit and Cinahl using defined search criteria, such as a focus on qualitative study designs. After the removal of duplicates, title/abstract and full text screening was carried out.
RESULTS
Final data extraction included 10 articles out of 12,633 records. Strategies regarding the post-acute care of newly diagnosed patients included providing clarity and comfort to the patients and giving support and information both pre- and post-diagnosis. Care efforts were focused on advanced care planning and deprescribing. Involving people with dementia and their caregivers in further care was seen as crucial to provide them with the support needed. GPs emphasised the importance of listening to concerns, as well as ensuring wishes are respected, and autonomy is maintained. All studies found communication between the GP setting and other healthcare professionals regarding post-acute care to be inadequate. Lack of information sharing, clinical notes and recommendations for the GP setting resulted in inefficient provision of support, as GPs feel limited in their ability to act.
DISCUSSION
Sharing necessary information with the GP setting could promote patient-centred care for people living with dementia and facilitate appropriate and timely resource allocation and effective healthcare collaboration between the settings, for example, by defining clear care pathways and clarifying roles and expectations.
Topics: Humans; Dementia; General Practitioners; Inpatients; Outpatients; Patient Transfer
PubMed: 38191313
DOI: 10.1186/s12877-023-04638-y -
The Korean Journal of Internal Medicine Jan 2024The effectiveness of remdesivir treatment in reducing mortality and the requirement for mechanical ventilation (MV) remains uncertain, as randomized controlled trials... (Meta-Analysis)
Meta-Analysis
BACKGROUND/AIMS
The effectiveness of remdesivir treatment in reducing mortality and the requirement for mechanical ventilation (MV) remains uncertain, as randomized controlled trials (RCTs) have produced conflicting results.
METHODS
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other data resources to find RCTs published prior to April 10, 2023. The selection of studies, assessment of risk of bias, and meta-analysis were conducted according to PRISMA guidelines. The primary outcomes were all-cause mortality and the need to initiate MV.
RESULTS
A total of 5,068 articles were screened, from eight RCTs comprising 11,945 patients. The meta-analysis found that, compared to standard care or placebo, remdesivir treatment provided no significant all-cause mortality benefit (pooled risk ratio [RR], 0.93; 95% confidence interval [CI], 0.85-1.02; 8 studies; high certainty evidence), while subgroup analyses revealed a trend towards reduced mortality among patients requiring oxygen but not MV (pooled RR, 0.88; 95% CI, 0.77-1.00; 6 studies; I2 = 4%). The need to initiate MV (pooled RR, 0.74; 95% CI, 0.59-0.94; 7 studies; moderate certainty evidence) in remdesivir-treated patients was also reduced compared to controls. Remdesivir significantly increased clinical improvement and discharge and significantly reduced serious adverse events.
CONCLUSION
In this systematic review and meta-analysis of RCTs, it was found that remdesivir treatment did not show a substantial decrease in the risk of mortality. However, it was linked to a reduction in the necessity for additional ventilatory support, suggesting remdesivir could be beneficial for COVID-19 patients, particularly those who are not on MV.
Topics: Humans; COVID-19; Respiration, Artificial; COVID-19 Drug Treatment; Patient Acuity; Adenosine Monophosphate; Alanine
PubMed: 38151918
DOI: 10.3904/kjim.2023.357 -
International Journal For Quality in... Dec 2023Although patient centredness is part of providing high-quality health care, little is known about the effectiveness of care transition interventions that involve... (Meta-Analysis)
Meta-Analysis
Although patient centredness is part of providing high-quality health care, little is known about the effectiveness of care transition interventions that involve patients and their families on readmissions to the hospital or emergency visits post-discharge. This systematic review (SR) aimed to examine the evidence on patient- and family-centred (PFC) care transition interventions and evaluate their effectiveness on adults' hospital readmissions and emergency department (ED) visits after discharge. Searches of Medline, CINAHL, and Embase databases were conducted from the earliest available online year of indexing up to and including 14 March 2021. The studies included: (i) were about care transitions (hospital to home) of ≥18-year-old patients; (ii) had components of patient-centred care and care transition frameworks; (iii) reported on one or more outcomes were among hospital readmissions and ED visits after discharge; and (iv) were cluster-, pilot- or randomized-controlled trials published in English or French. Study selection, data extraction, and risk of bias assessment were completed by two independent reviewers. A narrative synthesis was performed, and pooled odd ratios, standardized mean differences, and mean differences were calculated using a random-effects meta-analysis. Of the 10,021 citations screened, 50 trials were included in the SR and 44 were included in the meta-analyses. Care transition intervention types included health assessment, symptom and disease management, medication reconciliation, discharge planning, risk management, complication detection, and emotional support. Results showed that PFC care transition interventions significantly reduced the risk of hospital readmission rates compared to usual care [incident rate ratio (IRR), 0.86; 95% confidence interval (CI), 0.75-0.98; I2 = 73%] regardless of time elapsed since discharge. However, these same interventions had minimal impact on the risk of ED visit rates compared to usual care group regardless of time passed after discharge (IRR, 1.00; 95% CI, 0.85-1.18; I2 = 29%). PFC care transition interventions containing a greater number of patient-centred care (IRR, 0.73; 95% CI, 0.57-0.94; I2 = 59%) and care transition components (IRR, 0.76; 95% CI, 0.64-0.91; I2 = 4%) significantly decreased the risk of patients being readmitted. However, these interventions did not significantly increase the risk of patients visiting the ED after discharge (IRR, 1.54; CI 95%, 0.91-2.61). Future interventions should focus on patients' and families' values, beliefs, needs, preferences, race, age, gender, and social determinants of health to improve the quality of adults' care transitions.
Topics: Adult; Humans; Adolescent; Patient Transfer; Patient Discharge; Aftercare; Patient Readmission; Hospitals
PubMed: 38147502
DOI: 10.1093/intqhc/mzad102 -
Journal of Community Health Jun 2024In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is... (Review)
Review
In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.
Topics: Humans; HIV Infections; Pre-Exposure Prophylaxis; Aftercare; Anti-HIV Agents; Patient Discharge; Emergency Service, Hospital
PubMed: 38127296
DOI: 10.1007/s10900-023-01320-7 -
Medicine Dec 2023Immune system deregulation, including AAV, is a key event that may potentially evolve into ESRD. Abnormal activation of the cAP is also a cardinal feature of TMA,...
End stage renal disease in patient with microscopic polyangiitis and atypical hemolytic-uremic syndrome arose 3 weeks after the third dose of anti-SARS-CoV2 vaccine mRNA-1273: A case report with literature revision.
RATIONALE
Immune system deregulation, including AAV, is a key event that may potentially evolve into ESRD. Abnormal activation of the cAP is also a cardinal feature of TMA, particularly aHUS. The kidney is the most frequently involved organ, and renal-limited forms of TMA are often encountered in clinical practice. Isolated case reports described the occurrence of renal TMA in AAV patients. Some cases of both de novo and relapses of AAV and/or TMAs after anti-SARS-CoV2 vaccination have been reported. We reported, for the 1st time, a case of patients with new-onset MPA and aHUS occurring 3 weeks after the third dose of mRNA-1273 vaccine anti-SARS-CoV2.
PATIENT CONCERNS
We present a 67-year-old man, affected by arterial hypertension, reported, after mRNA-1273 vaccine anti-SARS-CoV2, anuria, fatigue, anorexia and nausea. Laboratory data revealed acute renal failure.
DIAGNOSIS
Positivity of MPO-ANCA was observed. 7 days after admission, we observed a worsening of anemia and thrombocytopenia with haptoglobin reduction, LDH increase and presence of schistocytes. Plasma levels of ADAMTS-13 were normal. A renal biopsy was performed, and findings were consistent with microscopic polyangiitis, with features of micro-thrombotic glomerulopathy. Genetic tests revealed absence of hybrid genes associated with the increased risk of aHUS.
INTERVENTIONS AND OUTCOMES
We started renal replacement treatment, including hemodialysis, and pulsed methylprednisolone, with no improvement of laboratory parameters. Then, plasma exchange was performed leading to partial haematological response. Only with Eculizumab, a human C5 inhibitor, we observed a normalization of haptoglobin levels and platelets' count. However, three months after discharge, the patient still required hemodialysis.
LESSONS
To our knowledge we observed the first case aHUS, without genetic predisposition, associated with MPA occurring after the third dose of anti-SARS-CoV2 vaccine. This case report highlights the potential link between anti-SARS-CoV2 vaccine as a trigger of MPA and aHUS. This systematic review offers additional perspectives. It is plausible to hypothesize that the vaccine was the trigger for the development of these 2 diseases.Solid evidence on the mechanisms of interaction between vaccine and immune system, the role of genetic predisposition, and other variables, will shed additional light on the controversial link between anti-SARS-CoV2 vaccine and autoimmunity.
Topics: Male; Humans; Aged; Atypical Hemolytic Uremic Syndrome; 2019-nCoV Vaccine mRNA-1273; Microscopic Polyangiitis; Haptoglobins; COVID-19; Kidney Failure, Chronic; Genetic Predisposition to Disease
PubMed: 38115241
DOI: 10.1097/MD.0000000000036560 -
International Journal of Pediatric... Jan 2024Paediatric otorrhoea (PO) describes a middle ear infection that results in a perforation of the tympanic membrane and ear discharge, in children and young people (CYP)....
INTRODUCTION
Paediatric otorrhoea (PO) describes a middle ear infection that results in a perforation of the tympanic membrane and ear discharge, in children and young people (CYP). Prolonged infection may be associated with hearing loss and developmental delay. The current management of paediatric otorrhoea is variable, including non-invasive treatments (conservative, oral antibiotics, topical antibiotics) and surgery, reflecting the lack of a sufficiently strong evidence base. Outcome reporting is fundamental to producing reliable and meaningful evidence to inform best practice.
OBJECTIVES
Primary objective: to determine which outcome measures are currently used to evaluate treatment success in studies of non-surgical treatments for paediatric otorrhoea.
SECONDARY OBJECTIVES
to identify outcome measurement instruments used in the literature and assess their applicability for use in clinical trials of PO.
METHODS
This systematic review was registered with PROSPERO (CRD42023407976). Database searches of EMBASE, MEDLINE and Cochrane was performed on June 6, 2023, covering from Jan 1995 to May 2023. Randomised controlled trials or study protocols involving CYP with PO were included following PRISMA guidelines. Risk of bias was assessed with Cochrane's tool.
RESULTS
Of the 377 papers identified, six were included in the systematic review. The primary outcome of five of the studies related to otorrhoea cessation; both time to cessation and proportion recovered at various time points were used as measures. Two measurement instruments were identified: Otitis Media-6 Questionnaire and the Institute for Medical Technology Assessment Productivity Cost Questionnaire. Both were shown to be applicable measurement instruments when used in clinical trials of PO.
CONCLUSIONS
To promote homogeneity and facilitate meaningful comparison and combination of studies, we propose that time to cessation of otorrhoea from onset of otorrhoea should be used as the primary outcome in future studies. Further research is needed to establish if this is the most important outcome to children and their caregivers.
Topics: Child; Humans; Adolescent; Otitis Media; Anti-Bacterial Agents; Ear Diseases; Treatment Outcome; Deafness
PubMed: 38103308
DOI: 10.1016/j.ijporl.2023.111820 -
The Lancet. Global Health Jan 2024Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also have an increased risk of mortality... (Meta-Analysis)
Meta-Analysis
Post-discharge malaria chemoprevention in children admitted with severe anaemia in malaria-endemic settings in Africa: a systematic review and individual patient data meta-analysis of randomised controlled trials.
BACKGROUND
Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also have an increased risk of mortality or readmission after hospital discharge. We conducted a systematic review and individual patient data meta-analysis to determine the efficacy of monthly post-discharge malaria chemoprevention in children recovering from severe anaemia.
METHODS
This analysis was conducted according to PRISMA-IPD guidelines. We searched multiple databases on Aug 28, 2023, without date or language restrictions, for randomised controlled trials comparing monthly post-discharge malaria chemoprevention with placebo or standard of care among children (aged <15 years) admitted with severe anaemia in malaria-endemic Africa. Trials using daily or weekly malaria prophylaxis were not eligible. The investigators from all eligible trials shared pseudonymised datasets, which were standardised and merged for analysis. The primary outcome was all-cause mortality during the intervention period. Analyses were performed in the modified intention-to-treat population, including all randomly assigned participants who contributed to the endpoint. Fixed-effects two-stage meta-analysis of risk ratios (RRs) was used to generate pooled effect estimates for mortality. Recurrent time-to-event data (readmissions or clinic visits) were analysed using one-stage mixed-effects Prentice-Williams-Peterson total-time models to obtain hazard ratios (HRs). This study is registered with PROSPERO, CRD42022308791.
FINDINGS
Our search identified 91 articles, of which 78 were excluded by title and abstract, and a further ten did not meet eligibility criteria. Three double-blind, placebo-controlled trials, including 3663 children with severe anaemia, were included in the systematic review and meta-analysis; 3507 (95·7%) contributed to the modified intention-to-treat analysis. Participants received monthly sulfadoxine-pyrimethamine until the end of the malaria transmission season (mean 3·1 courses per child [range 1-6]; n=1085; The Gambia), monthly artemether-lumefantrine given at the end of weeks 4 and 8 post discharge (n=1373; Malawi), or monthly dihydroartemisinin-piperaquine given at the end of weeks 2, 6, and 10 post discharge (n=1049; Uganda and Kenya). During the intervention period, post-discharge malaria chemoprevention was associated with a 77% reduction in mortality (RR 0·23 [95% CI 0·08-0·70], p=0·0094, I=0%) and a 55% reduction in all-cause readmissions (HR 0·45 [95% CI 0·36-0·56], p<0·0001) compared with placebo. The protective effect was restricted to the intervention period and was not sustained after the direct pharmacodynamic effect of the drugs had waned. The small number of trials limited our ability to assess heterogeneity, its sources, and publication bias.
INTERPRETATION
In malaria-endemic Africa, post-discharge malaria chemoprevention reduces mortality and readmissions in recently discharged children recovering from severe anaemia. Post-discharge malaria chemoprevention could be a valuable strategy for the management of this group at high risk. Future research should focus on methods of delivery, options to prolong the protection duration, other hospitalised groups at high risk, and interventions targeting non-malarial causes of post-discharge morbidity.
FUNDING
The Research-Council of Norway and the Bill-&-Melinda-Gates-Foundation through the Worldwide-Antimalarial-Research-Network.
Topics: Child; Humans; Child, Preschool; Antimalarials; Patient Discharge; Aftercare; Artemether; Artemether, Lumefantrine Drug Combination; Malaria; Anemia; Drug Combinations; Kenya; Chemoprevention; Randomized Controlled Trials as Topic
PubMed: 38097295
DOI: 10.1016/S2214-109X(23)00492-8