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CJEM Jul 2024People experiencing homelessness and marginalization face considerable barriers to accessing healthcare services. Increased reliance on technology within healthcare has...
OBJECTIVES
People experiencing homelessness and marginalization face considerable barriers to accessing healthcare services. Increased reliance on technology within healthcare has exacerbated these inequities. We evaluated a hospital-based prescription phone program aimed to reduce digital health inequities and improve access to services among marginalized patients in Emergency Departments. We examined the perceived outcomes of the program and the contextual barriers and facilitators affecting outcomes.
METHODS
We conducted a constructivist qualitative program evaluation at two urban, academic hospitals in Toronto, Ontario. We interviewed 12 healthcare workers about their perspectives on program implementation and outcomes and analyzed the interview data using reflexive thematic analysis.
RESULTS
Our analyses generated five interrelated program outcomes: building trust with patients, facilitating independence in healthcare, bridging sectors of care, enabling equitable care for marginalized populations, and mitigating moral distress among healthcare workers. Participants expressed that phone provision is critical for adequately serving patients who face barriers to accessing health and social services, and for supporting healthcare workers who often lack resources to adequately serve these patients. We identified key contextual enablers and challenges that may influence program outcomes and future implementation efforts.
CONCLUSIONS
Our findings suggest that providing phones to marginalized patient populations may address digital and social health inequities; however, building trusting relationships with patients, understanding the unique needs of these populations, and operating within a biopsychosocial model of health are key to program success.
PubMed: 38951473
DOI: 10.1007/s43678-024-00735-y -
Neurocritical Care Jul 2024The apnea test (AT) is an important component in the determination of brain death/death by neurologic criteria (BD/DNC) and often entails disconnecting the patient from...
BACKGROUND
The apnea test (AT) is an important component in the determination of brain death/death by neurologic criteria (BD/DNC) and often entails disconnecting the patient from the ventilator followed by tracheal oxygen insufflation to ensure adequate oxygenation. To rate the test as positive, most international guidelines state that a lack of spontaneous breathing must be demonstrated when the arterial partial pressure of carbon dioxide (PaCO) ≥ 60 mm Hg. However, the loss of positive end-expiratory pressure that is associated with disconnection from the ventilator may cause rapid desaturation. This, in turn, can lead to cardiopulmonary instability (especially in patients with pulmonary impairment and diseases such as acute respiratory distress syndrome), putting patients at increased risk. Therefore, this prospective study aimed to investigate whether a modified version of the AT (mAT), in which the patient remains connected to the ventilator, is a safer yet still valid alternative.
METHODS
The mAT was performed in all 140 BD/DNC candidates registered between January 2019 and December 2022: after 10 min of preoxygenation, (1) positive end-expiratory pressure was increased by 2 mbar (1.5 mm Hg), (2) ventilation mode was switched to continuous positive airway pressure, and (3) apnea back-up mode was turned off (flow trigger 10 L/min). The mAT was considered positive when spontaneous breathing did not occur upon PaCO increase to ≥ 60 mm Hg (baseline 35-45 mm Hg). Clinical complications during/after mAT were documented.
RESULTS
The mAT was possible in 139/140 patients and had a median duration of 15 min (interquartile range 13-19 min). Severe complications were not evident. In 51 patients, the post-mAT arterial partial pressure of oxygen (PaO) was lower than the pre-mAT PaO, whereas it was the same or higher in 88 cases. In patients with pulmonary impairment, apneic oxygenation during the mAT improved PaO. In 123 cases, there was a transient drop in blood pressure at the end of or after the mAT, whereas in 12 cases, the mean arterial pressure dropped below 60 mm Hg.
CONCLUSIONS
The mAT is a safe and protective means of identifying patients who no longer have an intact central respiratory drive, which is a critical factor in the diagnosis of BD/DNC. Clinical trial registration DRKS, DRKS00017803, retrospectively registered 23.11.2020, https://drks.de/search/de/trial/DRKS00017803.
PubMed: 38951444
DOI: 10.1007/s12028-024-02035-w -
Journal of General Internal Medicine Jul 2024There has been a growing disconnect between learners and educators within medical education. As the landscape of medical education has been altered post-pandemic and...
There has been a growing disconnect between learners and educators within medical education. As the landscape of medical education has been altered post-pandemic and cultural shifts favor "safe spaces," we sought to explore the tension that exists between a sense of safety and the discomfort inherent within the learning process. Through separate focus groups conducted with trainees and faculty, a common theme emerged: a sense of vulnerability. Trainees feel a strong sense of vulnerability when receiving feedback, particularly when given in public or when expectations were unclear. Educators feel a sense of vulnerability that their feedback will be interpreted as "retaliatory teaching." This sense of vulnerability was heightened in situations that emphasized the tension between personal well-being vs altruism, safe spaces vs accountability to high standards, and advocacy for system change vs power hierarchy. We must acknowledge this vulnerability and the resulting tensions that can ensue due to the competing commitments of medical training. By cultivating a culture of mutual growth and respect, we can create a learning environment that embodies the highest standards of medicine.
PubMed: 38951322
DOI: 10.1007/s11606-024-08893-6 -
The Journal of Medical Humanities Jul 2024This paper investigates the relationship between the experiences of mass vaccinations against two pandemic viruses: the swine flu in 2009-2010 and COVID-19 in the early...
This paper investigates the relationship between the experiences of mass vaccinations against two pandemic viruses: the swine flu in 2009-2010 and COVID-19 in the early 2020s. We show how distressing memories from the swine flu vaccination, which led to the rare but severe adverse effect of narcolepsy in approximately 500 children in Sweden, were triggered by the COVID-19 pandemic. The narcolepsy illness story has rarely been told in academic contexts; therefore, we will provide space for this story. It is presented through a dialogue with the aim of shedding light on the interrelationship between pandemics-and between mass vaccinations-to investigate what could be termed cultural wounds that influence societies because they are characterized by the difficulty of talking about them. The paper explores the multiple shocks of illness in life and what can be learned from them by sharing them.
PubMed: 38951319
DOI: 10.1007/s10912-024-09850-4 -
Maternal and Child Health Journal Jun 2024Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated...
INTRODUCTION
Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges.
METHODS
Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis.
RESULTS
Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use.
DISCUSSION
The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.
PubMed: 38951297
DOI: 10.1007/s10995-024-03959-7 -
International Urogynecology Journal Jul 2024The objective was to study the incidence of urinary incontinence (UI), associated risk factors and quality of life (QOL) in postpartum women.
INTRODUCTION AND HYPOTHESIS
The objective was to study the incidence of urinary incontinence (UI), associated risk factors and quality of life (QOL) in postpartum women.
METHODS
A prospective study was conducted with 406 postpartum women at Rajavithi Hospital and followed up over the phone between June 2020 and September 2021. Inclusion criteria were singleton pregnant women aged 18-45 years, and gestational age ≥ 37 weeks. Baseline characteristics (age, body mass index, birthweight, gestational age, parity, delivery type, smoking, and alcohol and caffeine intake) were recorded. UI was defined as a score ≥ 16.7% using the Urogenital Distress Inventory. Incontinence-related QOL was evaluated using the Incontinence Impact Questionnaire: a score of ≥ 70 indicated poor QOL. Outcomes were assessed during the postpartum period at 2 days, 6 weeks, 3 months, and 6 months. Multivariate logistic regression was used to analyze risk factors for UI.
RESULTS
The incidence of self-reported UI at 2 days, 6 weeks, 3 months, and 6 months postpartum were 39%, 3%, 1%, and 0% respectively. Caffeine consumption during pregnancy was only a risk factor for UI (adjusted RR 1.61, 95%CI 1.27-2.05, p < 0.001) after adjusting for age, BMI, birthweight, parity, delivery type, alcohol, smoking, and pelvic floor exercise. Three women with UI had poor QOL, whereas all women without UI reported a good QOL.
CONCLUSION
In our study sample, urinary incontinence was found in one-third of women during the early postpartum period, but for most women symptoms improved with the first 6 weeks and all resolved at 6 months. In this study, caffeine consumption during pregnancy was the only risk factor for UI.
PubMed: 38951165
DOI: 10.1007/s00192-024-05833-0 -
Social Psychiatry and Psychiatric... Jul 2024Anxiety sensitivity (AS) refers to fear of anxiety-related sensory arousal and has been revealed to be associated with increased psychological distress and mental...
PURPOSE
Anxiety sensitivity (AS) refers to fear of anxiety-related sensory arousal and has been revealed to be associated with increased psychological distress and mental problems. Although Anxiety Sensitivity Index-3 (ASI-3) has been confirmed to be effective in evaluating this construct, whether it is consistently applicable in college students is still elusive. The present study aimed to examine the psychometric properties and measurement invariance of Chinese version of ASI-3 (C-ASI-3) among college students experiencing campus lockdown due to novel coronavirus disease 2019 (COVID-19) pandemic.
METHODS
A total of 1532 Chinese college students (397, 25.9% males) aged between 16 and 25 were included in this study. Confirmatory factor analysis (CFA) was used to verify the factor structure of C-ASI-3. Multi-group CFA was conducted for analysis of measurement invariance with regard to gender. McDonald's omega values were computed for examination of scale reliability. For criterion, convergent, and divergent validity, average variance extracted (AVE) values for C-ASI-3 subscales, difference between square root of AVE for each factor and inter-factor correlation, as well as pearson correlation and partial correlation between the C-ASI-3 and other three scales, including the Depression, Anxiety, and Stress Scale-21 (DASS-21), the State-Trait Anxiety Inventory (STAI), and the Fear of COVID-19 scale (FCV-19 S) were evaluated.
RESULTS
The C-ASI-3 presented a three-factor scale structure with fit indices being as follows: χ/df = 11.590, CFI = 0.938, RMSEA = 0.083, SRMR = 0.042. Strict measurement invariance was reached across gender. Regarding convergent validity, the C-ASI-3 had a high correlation with the DASS-21 (r = 0.597, p < 0.01) and the STAI (r = 0.504, p < 0.01). All AVE values for C-ASI-3 subscales were above 0.5. In terms of divergent validity, the C-ASI-3 had medium correlation with the FCV-19 S (r = 0.360, p < 0.01). Square of root of AVE for each factor was higher that inter-factor correlation. McDonald's omega values of the three dimensions ranged from 0.898 ~ 0.958.
CONCLUSION
The C-ASI-3 has acceptable psychometric properties among college students. College students with different gender have consistent understanding on the scale construct.
PubMed: 38951154
DOI: 10.1007/s00127-024-02713-2 -
Scientific Reports Jul 2024Meditation, yoga, guided imagery, and progressive relaxation are promoted as complementary approaches for health and wellbeing in the United States, but their uptake by...
Meditation, yoga, guided imagery, and progressive relaxation are promoted as complementary approaches for health and wellbeing in the United States, but their uptake by different sociodemographic groups is unclear. This study assessed the prevalence and 20 year trends in the use of these practices in US adults between 2002-2022. We examined practice use and associations with sociodemographic and health factors in a population-weighted analysis of n = 134,959 participants across 5 cycles of the National Health Interview Survey. The overall use of meditation (18.3%, 60.53 million), yoga (16.8%, 55.78 million) and guided imagery/progressive relaxation (6.7%, 22.22 million) increased significantly from 2002 to 2022. Growth was consistent across most sociodemographic and health strata, however users of 'Other' race (comprising 54% Indigenous Americans, Odds Ratios; ORs = 1.28-1.70) and users with moderate (ORs = 1.19-1.29) psychological distress were overrepresented across all practices, and those with severe psychological distress were overrepresented in meditation (OR = 1.33) and guided imagery/progressive relaxation (OR = 1.42). Meditation use has accelerated over time for 65 + year olds (OR = 4.22), people not accessing mental health care (OR = 1.39), and less educated (OR = 4.02) groups, potentially reflecting unmet health needs. Health professionals should consider the extensive use of complementary practices in service and treatment planning and consider their risks and benefits.
Topics: Humans; Meditation; Yoga; Male; Female; Adult; United States; Middle Aged; Prevalence; Aged; Young Adult; Adolescent; Relaxation Therapy; Imagery, Psychotherapy
PubMed: 38951149
DOI: 10.1038/s41598-024-64562-y -
BMJ Open Jul 2024Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource...
Respiratory support with standard low-flow oxygen therapy, high-flow oxygen therapy or continuous positive airway pressure in adults with acute hypoxaemic respiratory failure in a resource-limited setting: protocol for a randomised, open-label, clinical trial - the Acute Respiratory Intervention...
RATIONALE
Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource constraints including limited access to invasive mechanical ventilation and/or highly skilled acute care workers. Continuous positive airway pressure (CPAP) and high-flow oxygen by nasal cannula (HFNC) may prove useful to reduce intubation, and therefore, improve survival outcomes among critically ill patients, particularly in resource-limited settings, but data in such settings are lacking. The aim of this study is to determine whether CPAP or HFNC as compared with standard oxygen therapy, could reduce mortality among adults presenting with AHRF in a resource-limited setting.
METHODS
This is a prospective, multicentre, randomised, controlled, stepped wedge trial, in which patients presenting with AHRF in Uganda will be randomly assigned to standard oxygen therapy delivered through a face mask, HFNC oxygen or CPAP. The primary outcome is all-cause mortality at 28 days. Secondary outcomes include the number of patients with criteria for intubation at day 7, the number of patients intubated at day 28, ventilator-free days at day 28 and tolerance of each respiratory support.
ETHICS AND DISSEMINATION
The study has obtained ethical approval from the Research and Ethics Committee, School of Biomedical Sciences, College of Health Sciences, Makerere University as well as the Uganda National Council for Science and Technology. Patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.
TRIAL REGISTRATION NUMBER
NCT04693403.
PROTOCOL VERSION
8 September 2023; version 5.
Topics: Humans; Continuous Positive Airway Pressure; Oxygen Inhalation Therapy; Respiratory Insufficiency; Prospective Studies; Uganda; Adult; Hypoxia; Randomized Controlled Trials as Topic; Multicenter Studies as Topic; Acute Disease; Resource-Limited Settings
PubMed: 38951007
DOI: 10.1136/bmjopen-2023-082223 -
British Journal of Sports Medicine Jul 2024There is a lack of prospective data on mental health of elite Para athletes. The objective was to identify and follow elite Para athletes at risk of mental health...
OBJECTIVE
There is a lack of prospective data on mental health of elite Para athletes. The objective was to identify and follow elite Para athletes at risk of mental health problems.
METHODS
In a 124-week prospective cohort study, mental health of German elite Para athletes was monitored using the Patient Health Questionnaire-4 (PHQ-4). In case of positive screening (PHQ-4≥5) over 2 weeks, a follow-up contact was conducted by a sports psychiatrist, who asked the athletes about their mental condition and sources for their mental distress and offered support.
RESULTS
7543 PHQ-4 scores were obtained from 122 Para athletes with a mean weekly response rate of 84%. The PHQ-4 screening was considered positive for symptoms of depression or anxiety with a prevalence of 6.7%, affecting 48.4% (n=59) of all participants at some point during the study period. In 76.6% (n=49) of all follow-up contacts, athletes (n=34) reported at least one mental health problem, most frequently mental distress (n=31), followed by symptoms of depression (n=19) including acute suicidality (n=1). The most common mental stressors cited were related to education and problems with the team, coaches or federation. At follow-up, almost two-thirds of the athletes were either already in professional psychiatric or psychological care (25%) or were recommended to seek such care (32.8%).
CONCLUSION
Our screening and follow-up system revealed high rates of mental health problems in elite Para athletes. Programmes for early identification with mental health monitoring under the supervision of mental health professionals should be considered by sports federations for Para athletes.
PubMed: 38950918
DOI: 10.1136/bjsports-2023-107995