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A 2014 study assessed infection prevention (IP) practices in Thai hospitals for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). This study compares current IP practices to results obtained in 2014.Between February 1, 2021 and August 31, 2021, we resurveyed Thai hospitals regarding practices to prevent CAUTI, CLABSI, and VAP. We also assessed COVID-19 impact and healthcare worker burnout and coping strategies. We distributed 100 surveys to a convenience sample of infection preventionists.Response rate: 100%. One-third (31%) of hospitals reported excellent leadership support for infection control (ie, responses of "good" or "excellent" to one survey question). Some prevention practices increased between 2014 vs 2021 (CAUTI: catheter reminder/stop-order/nurse-initiated discontinuation [50.0% vs 70.0%, P.001]; condom catheters [36.3% vs 51.0%, P = .01]; ultrasound bladder scanner [4.7% vs 12.0%, P = .03]; CLABSI: chlorhexidine gluconate insertion site antisepsis [73.6% vs 85.0%, P = .03]; maximum sterile barrier precautions [63.2% vs 80.0%, P = .003]; VAP: selective digestive tract decontamination [26.9% vs 40.0%, P = .02]). Antimicrobial catheter use decreased since 2014 (10.4% vs 3.0%, P.001). Many other practices remain suboptimal. COVID-19 challenges: staff shortages (71%), financial hardships (67%). Only 46% of infection preventionists felt safe working during COVID-19.More national strategic support is needed for IP programs to prevent CAUTI, CLABSI, VAP and healthcare worker well-being in Thailand during the COVID-19 pandemic.

Climate change is a global health crisis. In most regions, heat waves are expected to become longer and more frequent and air quality is expected to worsen. Few physicians discuss climate and health with patients, and related guidelines are lacking. Our objective was to quantify the prevalence of risk factors for illness related to climate change in the U.S. ambulatory setting.From the 2018 National Ambulatory Medical Care Survey, a national probability sample of nonfederal, ambulatory encounters, we identified adults with risk factors for illness related to heat or air pollution exposure.We found 91.4% of encounters involved a patient with at least 1 risk factor, while 46.7% had 2 or more.A high prevalence of patients with climate-related health risk factors exists in the ambulatory setting, representing a significant opportunity for evidence-based climate and health patient education and preventative care.

Youth with special health care needs often experience significant difficulty transitioning into adult health care services and adult life. Services supporting youths' transition from pediatric to adult health care (Health Care Transition (HCT)) have been a priority for nearly 30 years to improve this transition process. The Health Resources and Service Administration, Maternal and Child Health Bureau have measured HCT service provision since 2001 but the longitudinal use of this measure has never been examined (Blumberg, 2003; Maternal and Child Health Bureau, n.d.).This manuscript highlights the consistent and inconsistent uses of HCT constructs in two prominent national surveys (the National Survey of Children with Special Health Care Needs (NS-CSHCN) and the National Survey of Children's Health (NSCH)) between 2001 and 2019. All studies utilizing an HCT measure within a national survey between the 18 years were included in this examination.Significant changes have been made to the measurement of HCT service provision resulting in inconsistencies over the last 18 years. Measurement criteria and survey questions have changed substantially from the NS-CSHCN and NSCH limiting one's ability to examine trends in HCT since 2001. Since 2016, few changes have been made, allowing for analysis of trends over time. Importantly, the NSCH includes added questions pertaining to HCT that are not included in the composite HCT outcome measure.Future work should include a validation study of the HCT outcome in the National Survey of Children's Health and inclusion of additional HCT questions to promote continued and extensive use of a measure that more fully represents the needs of youth and their families.

Constipation is a common diagnosis in adults and children. Emergency department (ED) visits for constipation increased from 1980 to 2010. Since then, efforts have aimed to reduce resource utilization for constipation in the ED setting. Our objective is to examine contemporary ED practice patterns in the context of updated care guidelines.We conducted a cross-sectional study using the National Hospital Ambulatory Medical Care Survey from 2006 to 2017. Encounters with a constipation diagnosis were included. We examined rates of ED visits, diagnostic testing, and medication use. We also compared general and pediatric ED practice patterns for children.Approximately 1.3 million ED visits with a diagnosis of constipation occurred annually, with pediatric encounters comprising one-third of all visits. There was a 114% increase in ED visits for constipation over the study period. Urinalysis and imaging increased by 17% and 15%, respectively. Older patients were more likely to undergo diagnostic testing. No significant changes in laboratory testing, radiographs, or osmotic laxative prescriptions were observed among children. Compared to pediatric EDs, general EDs were more likely to perform CBC (29% vs. 15%) and urinalysis testing (42% vs 31%). General EDs were less likely to prescribe osmotic laxatives for children compared to pediatric EDs (26% vs. 37%).ED visits for constipation have increased significantly since 2006. Rates of diagnostic tests and prescriptions have not changed despite published evidence and guidelines that the diagnosis of constipation does not require imaging, and that the management of constipation requires consistent outpatient treatment. Opportunities exist to reduce ED resource utilization through knowledge dissemination and implementation.

Both traumatic and nontraumatic ocular issues often present to the emergency department. Understanding the epidemiology of ocular presentations to the emergency department not only informs current resource allocation, but also provides opportunities to evaluate the efficacy of prior healthcare access interventions.To characterize emergency department utilization in the United States for ophthalmic encounters between 2010 and 2018.Cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey database, a nationally representative sample of United States emergency department visits. 4284 deidentified emergency department patient encounters with an ICD-10 ophthalmic diagnosis from 2010 to 2018 were analyzed. The main outcome measures were the composition and characteristics of ophthalmic emergency department encounters over time.4284 ophthalmic visits were identified which represented an estimated 23.1 million visits (95% CI, 20.8 million-25.5 million). 31.6% (95% CI, 29.6-33.8) of ophthalmic visits were traumatic. Conjunctivitis was the most common non-traumatic diagnosis (32.8%, 95% CI, 30.7-35.0), while superficial injury of the cornea was the most common traumatic diagnosis (13.9%, 95% CI, 12.5-15.3). A greater proportion of emergency department visits involving the sclera and cornea were made by men (58.7%, 95% CI, 53.7%-63.6%; P = 0.02), whereas more women visited for visual disturbances (57.8%, 95% CI, 51.3%-64.4%; P = 0.01). Longitudinal trends of ophthalmic visits revealed an increase in public insurance payers in 2014, which corresponds to Medicaid expansion and implementation of mandated coverage for pediatric vision care. After stratification, this increase continued to be present in nontraumatic visits, but not traumatic ones.Ophthalmic emergency department visits in the United States between 2010 and 2018 were typically for non-traumatic eye issues. Diagnoses varied greatly by patient demographics, such as age and gender. Understanding these variations is valuable for preparing emergency departments for ocular presentations and providing guidance for future practice.

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (10%), medium (≥10 to35%), or high (≥35%).Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower cesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of cesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014.We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED.There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations.Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.

BACKGROUND: Neuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). METHODS: An electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. RESULTS: The survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. CONCLUSIONS: Neuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.

Objective In Japan, many otolaryngologists provide primary care for patients with coronavirus disease 2019 (COVID-19). The purpose of this study was to analyze the characteristics of otorhinolaryngological findings in order to improve COVID-19 diagnostic systems in a primary care setting. Methods A total of 351 patients (mean age, 36.0 ± 15.4 years) diagnosed with COVID-19 by otolaryngologists who belong to the Japan Otorhinolaryngologists Association were included in the study. A web-based questionnaire was used to collect information regarding the timing of positive identification of COVID-19, the route of infection, symptoms, and findings in the tonsils, nasal cavity, pharynx, ear, and neck. A modified Centor score was calculated for cases in which age, symptoms, and tonsil and neck findings were described. Results Symptoms included fever (56%), olfactory disturbance (46%), and a sore throat (56%). Of the individuals considered, 63% had ordinary rhinoscopic findings, 21% experienced watery rhinorrhea, and 12% had observable mucosal redness. Further, 87% had ordinary tonsillar findings, 13% displayed tonsillar redness, with enlargement and white mucus observe in 2% and 1% of participants, respectively. A total of 193 patients had a calculated Centor score of 3 points in 2%, and scores of the remaining participants were ≤2 points. Conclusion Of all patients considered, 40% had nasal findings and 4% had purulent nasal discharge. In contrast, only 13% of the patients had tonsillar findings, and no patients had Centor scores ≥4 points. Symptom differentiation from that of bacterial infections is difficult. In areas where COVID-19 is prevalent, the disease should be considered in patients presenting with fever, olfactory disturbances, and sore throat with minimal or no clinical findings in the nasal cavity and pharynx.

OBJECTIVE: To examine the use of pharmacotherapy in obesity treatment in the United States from 2011 to 2016 using a large, nationally representative sample. PATIENTS AND METHODS: Data were obtained over six years, 2011 to 2016, from the National Ambulatory Medical Care Survey. There were three types of visits identified: patients with obesity and an anti-obesity drug mention, patients with obesity and no anti-obesity drug mention, and patients without obesity and with anti-obesity drug mention. Chi-square tests were used to compare characteristics across each type of visit. To predict the odds of an anti-obesity medication mention for patients with obesity, a logistic regression analysis was conducted. RESULTS: Of the overall weighted 196,872,870 office-based physician visits made by patients with obesity from 2011 to 2016, one percent mentioned an anti-obesity drug. Additionally, there were 760,470 office-based physician visits by patients without obesity but with an anti-obesity medication mention. An anti-obesity drug mention was more likely for those ages 51 or older and those residing in the South (AOR: 5.31 95% CI: 1.19-23.59). CONCLUSION: There was a slight increase in anti-obesity medication mentions, from 0.26% in 2011 to 0.28% in 2016, but only one percent of office-based visits for patients with obesity received a prescription for an anti-obesity medication. Physicians tended to prescribe anti-obesity medications to those with obesity ages 51 or older and residing in the South. Anti-obesity medication as treatment for obesity is significantly underutilized.

PURPOSE: Parents of neonates with seizures are at risk of mental health symptoms due to the impact of illness on family life, prognostic uncertainty, and the emotional toll of hospitalization. A family-centered approach is the preferred model to mitigate these challenges. We aimed to identify strategies to promote family-centered care through an analysis of parent-offered advice to clinicians caring for neonates with seizures. BASIC PROCEDURES: This prospective, observational, and multi-center (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. Parents completed surveys about family well-being at 12 months, 18 months, and 24 months corrected gestational age. Parents were asked open-ended questions eliciting their advice to clinicians caring for neonates with seizures. Responses were analyzed using a conventional content analysis approach. MAIN FINDINGS: Among the 310 parents who completed surveys, 118 (38%) shared advice for clinicians. These parents were predominantly mothers (n=103, 87%). Three overarching themes were identified. (1) Communicate information effectively: Parents appreciate when clinicians offer transparent and balanced information in an accessible way. (2) Understand and validate parent experience: Parents value clinicians who display empathy, compassion, and a commitment to parent-partnered clinical care. (3) Provide support and resources: Parents benefit from emotional support, education, connection with peers, and help navigating the healthcare system. PRINCIPAL CONCLUSIONS: Parents caring for neonates with seizures appreciate a family-centered approach in healthcare encounters, including skilled communication, understanding and validation of the parent experience, and provision of support and resources. Future interventions should focus on building structures to reinforce these priorities.

Background The initial COVID-19 pandemic shutdown led to the canceling of elective surgeries throughout most of the USA and Canada. Objective This survey was carried out on behalf of the Parkinson Study Group (PSG) to understand the impact of the shutdown on deep brain stimulation (DBS) practices in North America. Methods A survey was distributed through RedCap® to the members of the PSG Functional Neurosurgical Working Group. Only one member from each site was asked to respond to the survey. Responses were collected from May 15 to June 6, 2020. Results Twenty-three sites participated; 19 (83%) sites were from the USA and 4 (17%) from Canada. Twenty-one sites were academic medical centers. COVID-19 associated DBS restrictions were in place from 4 to 16 weeks. One-third of sites halted preoperative evaluations, while two-thirds of the sites offered limited preoperative evaluations. Institutional policy was the main contributor for the reported practice changes, with 87% of the sites additionally reporting patient-driven surgical delays secondary to pandemic concerns. Pre-post DBS associated management changes affected preoperative assessments 96%; electrode placement 87%; new implantable pulse generator (IPG) placement 83%; IPG replacement 65%; immediate postoperative DBS programming 74%; and routine DBS programming 91%. Conclusion The COVID-19 pandemic related shutdown resulted in DBS practice changes in almost all North American sites who responded to this large survey. Information learned could inform development of future contingency plans to reduce patient delays in care under similar circumstances.

Background: Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care. Objective: The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities. Methods: PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included “NAMCS” or “National Ambulatory Medical Care Survey” and “disparity” or “disparities” as a pair or additionally paired with one of the following: “race”, “ethnicity”, “age”, “gender”, “geography”, or “insurance”. Results: 66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans. Limitations: Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses. Conclusions: NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Background Hospital reviews posted online by patients are unsolicited and less structured than Hospital Consumer Assessment of Healthcare Providers and Systems surveys. The differences between online review platforms and their degrees of correlation with validated satisfaction and safety measures are unknown. Methods We identified 515 large acute care teaching hospitals in the United States. We collected patient satisfaction results and postsurgical patient safety indicators from Hospital Compare. We also collected hospital star ratings (1–5) from Facebook, Google, and Yelp. Mean ratings were compared with paired t tests. Concordance between ratings websites, Hospital Consumer Assessment of Healthcare Providers and Systems scores, and surgical safety indicators were assessed with Pearson’s correlation coefficient. Results Mean Facebook ratings (3.81, interquartile range 3.5–4.3) were more favorable than Google (3.26, interquartile range 2.8–3.6) or Yelp (2.59, interquartile range 2.3–2.9). Facebook ratings were least strongly correlated with the Hospital Consumer Assessment of Healthcare Providers and Systems recommended hospital score (ρ = 0.356). Google was modestly correlated (ρ = 0.479), and Yelp was most strongly correlated (ρ = 0.500). The negative correlation between crowdsourced rating and composite safety indicator was too small to be meaningful on any platform. Conclusion There is variation between platforms in consumer ratings of hospitals. Ratings on Facebook are more favorable than Google or Yelp. These are independently correlated with Hospital Consumer Assessment of Healthcare Providers and Systems scores. These findings suggest that unstructured consumer reviews generally reflect similar directionality as Hospital Consumer Assessment of Healthcare Providers and Systems satisfaction scores. Users should be aware of the significant difference between platforms. Consumer ratings platforms are not consistently correlated with postsurgical patient safety indicators, so online ratings may not reflect the safety of surgical care received.

Background The COVID-19 pandemic led to rapid changes in clinical service delivery across hospital systems nationally. Local realities and resources were key driving factors impacting workflow changes, including for pediatric consultation-liaison psychiatry service (PCLPS) providers. Objective This study aims to describe the early changes implemented by 22 PCLPSs from the United States and Canada during the COVID-19 pandemic. Understanding similarities and differences in adaptations made to PCLPS care delivery can inform best practices and future models of care. Methods A 20-point survey relating to PCLPS changes during the COVID-19 pandemic was sent to professional listservs. Baseline hospital demographics, hospital and PCLPS workflow changes, and PCLPS experience were collected from March 20 to April 28, 2020, and from August 18 to September 10, 2020. Qualitative data were collected from responding sites. An exploratory thematic analysis approach was used to analyze the qualitative data that were not dependent on predetermined coding themes. Descriptive statistics were calculated using Microsoft Excel. Results Twenty-two academic hospitals in the United States and Canada responded to the survey, with an average of 303 beds/hospital. Most respondents (18/22) were children's hospitals. Despite differences in regional impact of COVID-19 and resource availability, there was significant overlap in respondent experiences. Restricted visitation to one caregiver, use of virtual rounding, ongoing trainee involvement, and an overall low number of COVID-positive pediatric patients were common. While there was variability in PCLPS care delivery occurring virtually versus in person, all respondents maintained some level of on-site presence. Technological limitations and pediatric provider preference led to increased on-site presence. Conclusions To our knowledge, this is the first multicenter study exploring pandemic-related PCLPS changes in North America. Findings of this study demonstrate that PCLPSs rapidly adapted to COVID-19 realities. Common themes emerged that may serve as a model for future practice. However, important gaps in understanding their effectiveness and acceptability need to be addressed. This multisite survey highlights the importance of establishing consensus through national professional organizations to inform provider and hospital practices.

Objectives At 3 months after the intervention, this study evaluates the cost-effectiveness of a 3-week inpatient pulmonary rehabilitation (PR) in patients with asthma compared with usual care alongside the single-center randomized controlled trial—Effectiveness of Pulmonary Rehabilitation in Patients With Asthma. Methods Adopting a societal perspective, direct medical costs and productivity loss were assessed using the Questionnaire for Health-Related Resource Use-Lung, a modification of the FIM in an Elderly Population. The effect side was operationalized as minimal important differences (MIDs) of the Asthma Control Test (ACT) and the Asthma Quality of Life Questionnaire (AQLQ) and through quality-adjusted life-years (QALYs) gained. Adjusted mean differences in costs (gamma-distributed model) and each effect parameter (Gaussian-distributed model) were simultaneously calculated within 1000 bootstrap replications to determine incremental cost-effectiveness ratios (ICERs) and to subsequently delineate cost-effectiveness acceptability curves. Results PR caused mean costs per capita of €3544. Three months after PR, we observed higher mean costs (Δ€3673; 95% confidence interval (CI) €2854-€4783) and improved mean effects (ACT Δ1.59 MIDs, 95% CI 1.37-1.81; AQLQ Δ1.76 MIDs, 95% CI 1.46-2.08; QALYs gained Δ0.01, 95% CI 0.01-0.02) in the intervention group. The ICER was €2278 (95% CI €1653-€3181) per ACT-MID, €1983 (95% CI €1430-€2830) per AQLQ-MID, and €312 401 (95% CI €209 206-€504 562) per QALY gained. Conclusions Contrasting of PR expenditures with ICERs suggests that the intervention, which achieves clinically relevant changes in asthma-relevant parameters, has a high probability to be already cost-effective in the short term. However, in terms of QALYs, extended follow-up periods are likely required to comprehensively judge the added value of a one-time initial investment in PR.

Objective We studied physicians’ opinions and experiences concerning clinical concerns, perceived severity, occurrence, and management of baclofen withdrawal due to abrupt discontinuation. Methods A nationwide 26-question electronic survey was distributed via e-mail to physicians (N = 952) representing varying specialties who manage spasticity with baclofen. A total of 110 physicians provided responses to the survey (response rate = 11.6%). Results were evaluated using descriptive statistics. Results Withdrawal from both oral and intrathecal (IT) baclofen was recognized as a significant concern and was observed by most respondents. However, approximately 75% and 35% of respondents or their clinic sites lack established management protocols for managing anticipated interruption of oral or IT baclofen, respectively. Conclusions These findings highlight the need for further research on and the development of guidelines for the prevention and treatment of baclofen withdrawal. The results of this survey, along with a systematic literature review and multidisciplinary stakeholder input, may be helpful in establishing guidelines for the treatment and prevention of baclofen withdrawal.

Purpose Homeless young adults often seek health care at emergency departments (EDs) after they are no longer able to ignore a pressing health problem. However, a dearth of literature examines homeless young adults' ED visits. This study aimed to increase understanding of ED visits among homeless young adults within the U.S. Methods Data for this study were obtained from the 2011–2015 National Hospital Ambulatory Medical Care Survey. The sample for this study included all ED visits made by homeless and housed young adults aged 18–29 years (unweighted N = 25,068). Results ED visits by homeless young adults were distinguished in terms of gender, region, payment sources, and triage level. Furthermore, ED visits made by homeless young adults were more likely related to mental health and suicide. Homeless young adults' ED visits were characterized by a longer average length of stay and were less likely to be referred to a physician or clinic for follow-up, given medication, or have a procedure performed in the ED. Conclusions This study highlighted differences in ED utilization for homeless young adults. The findings of this study suggest a need to further examine the characteristics of ED services received by homeless young adults to better understand differences in ED service receipt related to housing status. This knowledge can inform efforts to reduce costs through improving access to housing and outpatient mental health care and reducing stigma among health care professionals to ensure continuity of care.

Objectives To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. Study design Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. Results Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. Conclusions Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. Implications statement Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Objectives To evaluate the concordance between maternal report of antepartum tetanus, diphtheria, pertussis (Tdap) vaccination and vaccination status documented in the electronic medical record (EMR), as well as factors associated with discordance. Study design A survey was completed by a convenience sample of postpartum patients in a New York metropolitan hospital. The survey collected patients’ demographic information, health beliefs, and whether they received Tdap vaccine during this pregnancy. The patient's Tdap vaccination status was abstracted from the EMR, a combination of data gathered from the obstetrician and patient's hospital record. Kappa statistics measured the agreement between maternal report and EMR on antepartum Tdap vaccination. Univariate and multivariable logistic regression analyses were performed to identify maternal characteristics associated with discordance. Results Of the 1571 patients with Tdap status available in the EMR, 1549 patients (92%) reported on receipt status for Tdap vaccination during pregnancy; 1328 maternal reports (86%) agreed with the EMR for Tdap status (kappa = 0.72, 95% CI 0.68-0.75). Several factors were statistically significant in multivariable analyses: lower income was associated with greater discordance (ie, overreporting; P = .02), as well as certain health beliefs including “Pregnant women should be concerned about the possibility of pertussis in their babies” (aOR 2.86, 95% CI 1.02-8.04) and “My friends would probably think getting a Tdap vaccine is a good idea” (aOR 2.36, 95% CI 1.11-4.99). Conclusions Maternal recall of Tdap vaccination during pregnancy is consistent with the EMR. This supports the value of maternal report in determining Tdap vaccination status, which is especially important when vaccination records are not available.

Background The process of developing a survey instrument to evaluate women’s experiences of their maternity care is complex given that maternity care encapsulates various contexts, services, professions and professionals across the antenatal, intranatal and postnatal periods. Aim To identify and prioritise items for inclusion in the National Maternity Experience Survey, a survey instrument to evaluate women’s experiences of their maternity care in the Republic of Ireland. Methods This study used an adapted two-phase exploratory sequential mixed methods design. Phase one identified items for possible inclusion and developed an exhaustive item pool through a systematic review, focus groups and one to one interviews, and a gap analysis. Phase two prioritised the items for inclusion in the final item bank through a Delphi study and consensus review. Findings Following iterative consultation with key stakeholder groups, a bank of 95 items have been prioritised and grouped within eight distinct care sections; care during your pregnancy, care during your labour and birth, care in hospital after the birth of your baby, specialised care for your baby, feeding your baby, care at home after the birth of your baby, overall care and you and your household. Conclusion Robust and rigorous methods have been used to develop a bank of 95 suitable items for inclusion in the National Maternity Experience Survey.

Objectives We explored public opinion about using telemedicine to provide medication abortion during the COVID-19 pandemic in 2020. We also investigated the associations between socio-demographic characteristics and support for using telemedicine in this context and explored factors that influenced respondents’ attitudes on the topic. Study design In a nationally representative, web-based survey of US adults (n = 711), we asked open- and closed-ended questions about using telemedicine to prescribe medication abortion during COVID-19. We used multinomial logistic regression to assess the relationship between socio-demographic characteristics, endorsement of abortion labels, and political affiliation and support for telemedicine in this circumstance. Then, we conducted content and thematic analyses with the open-ended data to explore what influenced respondents’ opinions. Results Overall, 332 (44%) of respondents supported using telemedicine for medication abortion during the pandemic; 237 (35%) opposed and 138 (21%) were unsure. Respondents who identified as prochoice were more likely to support using telemedicine for abortion during the pandemic than those who identified as prolife were to oppose it in this context (RRR 2.95; 95% CI 1.31–6.64). Via our content and thematic analysis, we identified that concerns about safety, the legitimacy of telemedicine, and the belief that abortion should occur as early in the pregnancy as possible influenced respondents’ beliefs about using telemedicine for medication abortion. Conclusions More respondents supported using telemedicine for medication abortion during COVID-19 than opposed it. Among respondents who expressed support, most thought that medication abortion was safe and that telemedicine was equivalent to the in-person provision of care. Implications There appears to be support among US adults for the provision of medication abortion via telemedicine during COVID-19. Policymakers may consider public sentiment as well as clinical evidence when considering legislation about abortion.

Graphical abstract, Introduction The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. Method A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. Results We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. Conclusion Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

COVID-19 brought telemedicine to the forefront of clinical cardiology. We aimed to examine the extent of trainees' involvement in and comfort with telemedicine practices in Canada with the use of a web-based self-administered survey. Eighty-six trainees from 12 training programs completed the survey (65% response rate). Results showed that before COVID-19, 39 trainees (45%) had telemedicine exposure, compared with 67 (78%) after COVID-19 (P < 0.001). However, only 44 trainees (51%) reported being comfortable or very comfortable with the use of telemedicine. Of the 67 trainees who were involved in telemedicine, 4 (6%) had full supervision during virtual visits, 13 (19%) had partial supervision, and 50 (75%) had minimal or no supervision. Importantly, 67 trainees (78%) expressed the need for telemedicine-specific training and 64 (74%) were willing to have their virtual visits recorded for the purpose of evaluation and feedback. Furthermore, 47 (55%) felt strongly or very strongly positive about incorporating telemedicine into their future practice. The main perceived barriers to telemedicine use were concerns about patients' engagement, fear of weakening the patient-physician relationship, and unfamiliarity with telemedicine technology. These barriers, together with training in virtual physical examination skills and medicolegal aspects of telemedicine, are addressed in several established internal medicine telemedicine curricula that could be adapted by cardiology programs. In conclusion, while the degree of telemedicine involvement since COVID-19 was high, the trainees' comfort level with telemedicine practice remains suboptimal likely due to lack of training and inadequate staff supervision. Therefore, a cardiology telemedicine curriculum is needed to ensure that trainees are equipped to embrace telemedicine in cardiovascular clinical care.

Graphical Abstract fx1, Resumen español Introducción: La pandemia COVID-19 ha tenido una repercusión extraordinaria sobre los hospitales españoles, que han reorganizado sus recursos para tratar a estos pacientes, limitando su capacidad de atender otras patologías frecuentes. El presente estudio analiza la repercusión sobre el tratamiento de la colelitiasis y la colecistitis aguda. Métodos: Se ha realizado un estudio nacional descriptivo mediante una encuesta online voluntaria, realizada en Google Drive™, distribuida por correo electrónico desde la Asociación Española de Cirujanos (AEC) a todos los cirujanos miembros. Resultados: Se han recibido 153 encuestas (una por centro). El 96.7% de ellos han suspendido las colecistectomías electivas. El tratamiento conservador de la colecistitis aguda no complicada se ha realizado en un 90% de los casos (siendo previamente del 18%) y, en las colecistitis intervenidas, el 95% ha optado por abordaje laparoscópico. Un 49% realiza algún test preoperatorio para SARS-CoV-2, y el 57% comunican haber tenido casos de confirmación postoperatoria tras alguna intervención, con peor evolución postoperatoria en el 54%. Conclusiones: Esta encuesta revela que las mayorías de los centros están siguiendo las recomendaciones de las sociedades quirúrgicas durante la pandemia por COVID-19. Sin embargo, se observan algunos datos que precisan ser tenido en cuenta en la fase sucesivas de la pandemia.

Objectives The COVID-19 pandemic has serious social, economic and health consequences. Particularly in these times, it is important to maintain individual health. Therefore, it is important to take part in routine health checkups. Consequently, our objective was to describe the frequency and to identify the determinants of postponed routine health checkups. Study design Cross-sectional data from the nationally representative online-survey “COVID-19 Snapshot Monitoring in Germany (COSMO)” was used (wave 17; July 2020). Methods In sum, 974 individuals were included in our analytical sample (average age was 45.9 years, SD: 16.5, 18–74 years). Postponed routine health checkups (yes or no) since March 2020 due to the COVID-19 pandemic were assessed. Results More than 16% of the individuals reported postponed routine health checkups in the past few months due to the COVID-19 pandemic. Particularly, individuals aged 30–49 years had postponed health checkups (21%). The probability of postponed health checkups was positively associated with the presence of chronic diseases (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.15–2.47), higher affect regarding COVID-19 (OR: 1.44, 95%-CI: 1.16–1.78), and higher presumed severity of COVID-19 (OR: 1.17, 95%-CI: 1.01–1.35), whereas the outcome measure was not associated with socioeconomic factors. Data showed that a sizeable part (about one of six individuals) of the population reported postponed routine health checkups due to the COVID-19 pandemic between March and July 2020. Conclusions Postponed checkups should not be neglected during the COVID-19 pandemic. Individuals at risk for postponed health checkups should be appropriately addressed.

To assess the relationship between remote digital monitoring (RDM) modalities for diabetes and intrusiveness in patients' lives.Online vignette-based survey (February 1 through July 1, 2019). Adults with diabetes (type 1, 2, or subtypes such as latent autoimmune diabetes of adulthood) assessed three randomly selected vignettes among 36 that combined different modalities for monitoring tools (three options: glucose- and physical activity [PA]-monitoring only, or glucose- and PA-monitoring with occasional or regular food monitoring), duration/feedback loops (six options: monitoring for a week before all vs before specific consultations with feedback given in consultation, vs monitoring permanently, with real-time feedback by one's physician vs by anoter caregiver, vs monitoring permanently, with real-time, artificial intelligence-generated treatment feedback vs treatment and lifestyle feedback), and data handling (two options: by the public vs private sector). We compared intrusiveness (assessed on a 5-point scale) across vignettes and used linear mixed models to identify intrusiveness determinants. We collected qualitative data to identify aspects that drove participants' perception of intrusiveness.Overall, 1010 participants from 30 countries provided 2860 vignette-assessments (52% were type 1 diabetes). The monitoring modalities associated with increased intrusiveness were food monitoring compared with glucose- and PA-monitoring alone (β=0.34; 95% CI, 0.26 to 0.42; P.001) and permanent monitoring with real-time physician-generated feedback compared with monitoring for a week with feedback in consultation (β=0.25; 95% CI, 0.16 to 0.34, P.001). Public-sector data handling was associated with decreased intrusiveness as compared with private-sector (β=-0.15; 95% CI, -0.22 to -0.09; P.001). Four drivers of intrusiveness emerged from the qualitative analysis: practical/psychosocial burden (eg, RDM attracting attention in public), control, data safety/misuse, and dehumanization of care.RDM is intrusive when it includes food monitoring, real-time human feedback, and private-sector data handling.

Background In this study, we sought to assess knowledge, attitudes, and behaviors regarding venous thromboembolism (VTE) prophylaxis among clinicians at a tertiary hospital of China. Methods An electronic questionnaire was sent to clinicians to gather information regarding demographic data (5 items), knowledge about VTE prophylaxis (21 items), behaviors regarding VTE prophylaxis (8 items), and attitudes regarding VTE prophylaxis (7 items). Answers of “strongly agree” and “agree” on the behaviors and attitude items were defined as affirmative responses. Clinicians were also asked to provide suggestions regarding VTE prophylaxis. Results A total of 867 clinicians were included in this study. The overall correct response rate for knowledge items was 60.9%. The median affirmative response rate for behavior items was 48.6% (range 29.5–80.3%), and the median affirmative response rate for attitude items was 98.7% (range 96.9–99.3%). Clinicians were most concerned about the adverse effects triggered by chemical VTE prophylaxis (79.5%) and possibility of a financial penalty when a patient could not be treated with VTE prophylaxis (72.3%). Low patient compliance and low level of clinician knowledge and participation were identified most commonly as difficulties involved in VTE prophylaxis. A total of 78 suggestions were collected; these suggestions generally focused on improving the quality and frequency of staff training (n = 24) and enhancing learning opportunities (n = 22). Conclusions Although the clinicians’ overall attitude toward VTE prophylaxis was positive, the knowledge level was relatively poor, and the rate of affirmative responses regarding behaviors was low. Medical institutions should improve clinician training regarding VTE prophylaxis.

Background Physician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010–2017. Methods A retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. Results Between 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25–44 years old (yo) (32.9%, ±6.2%) and 15–24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%). Conclusions From 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.

Purpose When treating cancer, both quantity and quality of life are valuable, though oncology trials have long placed greater emphasis on the former. The goal of this work was to evaluate how patient-reported outcomes (PROs) have been incorporated into radiation therapy trials within the National Clinical Trials Network over the last 2 decades to measure quality of life and to assess how PRO data have been disseminated in publications upon trial conclusion. Methods and Materials This cross-sectional study analyzed the frequency of use of PROs in National Clinical Trials Network cooperative group radiation therapy phase 2 and 3 clinical trials over the past 2 decades. A literature review was performed to determine the publication outcomes of PRO data, including only trials that used PROs in their design and were mature enough to have published results. Results Fifty-seven (56.4%) of the 101 trials included in this study included PROs in their design. Brain and head and neck trials demonstrated the largest proportional incorporation of PROs (81.8% and 76.9%, respectively), and thoracic and breast trials used the fewest (18.8% and 37.5%, respectively). The EQ-5D family of questionnaires was the most commonly used PROs, used in 22.8% of trials included. The literature review demonstrated a pattern of increased publication of PRO data alongside survival endpoints in manuscripts derived from these trials over time. Conclusions Though there is room for improvement, the field of radiation oncology has embraced the incorporation of PROs into multicenter, high-impact clinical trials over the past 2 decades and has increased its publication of this data alongside survival data from these trials.

Objective International guidelines recommend pneumococcal pneumonia and influenza vaccination for all patients with solid organ malignancies prior to initiating chemotherapy. Baseline vaccination rates (March 2019) for pneumococcal pneumonia and influenza at our tertiary cancer centre were 8% and 40%, respectively. The aim of this study was to increase the number of gynecologic chemotherapy patients receiving pneumococcal and influenza vaccinations to 80% by March 2020. Methods We performed an interrupted time series study using structured quality improvement methodology. Three interventions were introduced to address vaccination barriers: an in-house vaccination program, a staff education campaign, and a patient care bundle (pre-printed prescription, information brochure, vaccine record booklet). Process and outcome data were collected by patient survey and pharmacy audit and analyzed on statistical process control charts. Results We identified 195 eligible patients. Pneumococcal and influenza vaccination rates rose significantly from 5% to a monthly mean of 61% and from 36% to a monthly mean of 67%, respectively. The 80% target was reached for both vaccines during one or more months of study. The in-house vaccination and staff education programs were major contributors to the improvement, whereas the information brochure and record booklet were minor contributors. Conclusions Three interventions to promote pneumococcal and influenza vaccination among chemotherapy patients resulted in significantly improved vaccination rates. Lessons learned about promoting vaccine uptake may be generalizable to different populations and vaccine types. In response to the global COVID-19 pandemic, initiatives to expand the program to all chemotherapy patients at our centre are underway.

Summary Background Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently associated with impaired oral intake and malnutrition, which potentially increases morbidity and mortality. Therefore, nutrition is one of the major challenges in the post-transplant period. Methods To document the current clinical approach in nutritional treatment, we designed a questionnaire concerning the current practice in nutrition after alloHSCT and distributed it to German speaking centers performing alloHSCT in Germany, Austria and Switzerland between November 2018 and March 2020. Twenty-eight (39%) of 72 contacted centers completed the survey, 23 from Germany, two from Austria and three from Switzerland, representing 50% of alloHSCT activity within the participating countries in 2018. Results All centers reported having nutritional guidelines for patients undergoing alloHSCT, whereby 86% (n = 24) provided a low-microbial diet during the neutropenic phase. The criteria to start parenteral nutrition (PN) directly after alloHSCT seemed to be consistent, 75% (n = 21) of the corresponding centers started PN if the oral nutritional intake or the bodyweight dropped below a certain limit. In the setting of intestinal graft-versus-host disease (GvHD) the current practice appeared to be more heterogenous. About 64% (n = 18) of the centers followed a special diet, added food stepwise modulated by GvHD symptoms, while only four centers regularly stopped oral intake completely (intestinal GvHD grade >1). Half of the centers (54%, n = 15) applied a lactose-free diet, followed by 43% (n = 12) which provided fat- and 18% (n = 5) gluten-free food in patients with intestinal GvHD. Supplementation of micronutrients in acute intestinal GvHD patients was performed by 54% (n = 15) of the centers, whereas vitamin D (89%, n = 25) and vitamin B12 (68%, n = 19) was added regularly independently of the presence of GvHD. Only 5 (18%) participating centers ever observed a food-associated infection during hospitalization, whereas food-associated infections were reported to occur more often in the outpatient setting (64%, n = 18). Conclusion The survey documented a general consensus about the need for nutritional guidelines for patients undergoing alloHSCT. However, the nutritional treatment in clinical practice (i.e. lactose-, gluten- or fat-free in intestinal GvHD) as well as the use of food supplements was very heterogeneous. In line with current general recommendations the centers seemed to focus on safe food handling practice rather than providing a strict neutropenic diet. More high-quality data are required to provide evidence-based nutrition to patients during and after alloHSCT.

Objectives To assess the rate of cesarean delivery at Basurto University Hospital (Bilbao, Spain) between 2015 and 2017 and to determine the cause of an increase in this rate during 2017. Methods We retrospectively reviewed 6975 deliveries between 2015 and 2017, classifying women using the Robson classification. We analyzed extended perinatal mortality and perinatal outcomes during the study period and performed a comparative analysis of cesarean deliveries by year and Robson group. Comparisons were made with analysis of variance and χ2 or Fisher's exact tests. Results During the study period, 928 cesarean deliveries (13.3%) were performed. Extended perinatal mortality in this period was 7.0%. We detected an increase in the rate of cesarean delivery in 2017 in Group 1 women (P = 0.0224), with significant differences in the homogeneity of the distribution of cesarean deliveries performed for fetal distress between years in this group (P = 0.0093). Auditing the cases of cesareans performed for fetal distress in Group 1 in 2017, we found that the indication was appropriate in all cases, but in 39.4%, the management of uterine contractions during labour was considered suboptimal. Conclusion Classifying cesarean deliveries using the Robson classification allows us to compare cesarean rates in different years and analyze any increases in these rates. Increases are sometimes attributed to changes in the obstetric population, but when investigated may be found to be related to potentially correctable problems. It is not necessary to have a high rate of cesarean delivery to warrant internal audit.

Objective: The characteristics and outcomes of patients undergoing vascular surgery hospitalised and managed in Lombardy are described with a comparison of patients tested positive for COVID-19 (CV19-pos) vs. those tested negative (CV19-neg). Methods: This was a multicentre, retrospective, observational cohort study which involved all vascular surgery services in Lombardy, Northern Italy. Data were retrospectively merged into a combined dataset covering the nine weeks of the Italian COVID-19 pandemic phase 1 (8 March 2020 to 3 May 2020). The primary outcome was freedom from in hospital death, secondary outcomes were re-thrombosis rate after peripheral revascularisation, and freedom from post-operative complication. Results: Among 674 patients managed during the outbreak, 659 (97.8%) were included in the final analysis: 121 (18.4%) were CV19-pos. CV19-pos status was associated with a higher rate of complications (OR 4.5; p < .001, 95% CI 2.64 – 7.84), and a higher rate of re-thrombosis after peripheral arterial revascularisation (OR 2.2; p = .004, 95% CI 1.29 – 3.88). In hospital mortality was higher in CV19-pos patients (24.8% vs. 5.6%; OR 5.4, p < .001;95% CI 2.86 – 8.92). Binary logistic regression analysis identified CV19-pos status (OR 7.6; p < .001, 95% CI 3.75 – 15.28) and age > 80 years (OR 3.2; p = .001, 95% CI 1.61 – 6.57) to be predictors of in hospital death. Conclusion: In this experience of the vascular surgery group of Lombardy, COVID-19 infection was a marker of poor outcomes in terms of mortality and post-operative complications for patients undergoing vascular surgery treatments.

Surgery is a common gateway to opioid-related morbidity. Ambulatory anorectal cases are common, with opioids widely prescribed, but there is limited data on their role in this crisis. We sought to determine prescribing trends, new persistent opioid use rates, and factors associated with new persistent opioid use after ambulatory anorectal procedures.The Optum Clinformatics claims database was analyzed for opioid-naïve adults undergoing outpatient hemorrhoid, fissure, or fistula procedures from January 1, 2010, to June 30, 2017. The main outcome measure was the rate of new persistent opioid use after anorectal cases. Secondary outcomes were annual rates of perioperative opioid fills and the prescription size over time (oral morphine equivalents).A total of 23,426 cases were evaluated: 69.09% (n = 16,185) hemorrhoids, 24.29% (n = 5,690) fissures, and 6.45% (n = 1,512) fistulas. The annual rate of perioperative opioid fills decreased on average 1.2%/year, from 72% in 2010 to 66% in 2017 (P.001). Prescribing rates were consistently highest for fistulas, followed by hemorrhoids, then fissures (P.001). There was a significant reduction in prescription size (oral morphine equivalents) over the study period, with median oral morphine equivalents (interquartile range) of 280 (250-400) in 2010 and 225 (150-375) in 2017 (P.0001). Overall, 2.1% (n = 499) developed new persistent opioid use. Logistic regression found new persistent opioid use was associated with additional perioperative opioid fills (odds ratio 3.92; 95% confidence interval: 2.92-5.27; P.0001), increased comorbidity (odds ratio 1.15; confidence interval: 1.09-1.20; P.00001), tobacco use (odds ratio 1.79; confidence interval: 1.37-2.36; P.0001), and pain disorders (odds ratio, 1.49; confidence interval, 1.23-1.82); there was no significant association with procedure performed.Over 2% of ambulatory anorectal procedures develop new persistent opioid use. Despite small annual reductions in opioid prescriptions, there has been little change in the amount prescribed. This demonstrates a need to develop and disseminate best practices for anorectal surgery, focusing on eliminating unnecessary opioid prescribing.

Objective To measure patient preferences for attributes associated with thermal ablation and non-thermal, non-tumescent varicose vein treatments. Methods Data were collected from an electronic patient-preference survey taken by 70 adult participants (aged 20 years or older) at 3 Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed 3 hypothetical treatment scenarios with different combinations of 6 attributes of interest and a “None” option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and non-thermal, non-tumescent treatments. Results Of the 6 attributes studied, out-of-pocket expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of out-of-pocket spending, 60%-80% of respondents favored attribute combinations corresponding to non-thermal, non-tumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost-sharing. Conclusions Patients are highly sensitive to out-of-pocket costs for minimally-invasive varicose vein treatments. Market simulation analysis favored non-thermal, non-tumescent procedures over thermal ablation.

OBJECTIVES: This study examined the association of ED use in the first year of diagnosis and patient experiences in care among older adults with hematologic malignancies. MATERIALS AND METHODS: Cross-sectional design using SEER-CAHPS® data from 2002-2015 to study Medicare fee-for-service enrollees with a primary diagnosis of leukemia or lymphoma. We linked the CAHPS survey data (patient-reported experiences with health services) to patients’ cancer registry information and Medicare outpatient claims from the SEER-CAHPS resource. We estimated associations of ED use and clinical characteristics with two CAHPS outcomes – “getting care quickly” (timeliness) and “getting needed care” (access) – with bivariate and multivariate analyses. RESULTS: The analytic sample included 751 patients, 125 of whom had an ED claim in the first year of cancer diagnosis. The most frequent ED diagnosis clusters were fever and infection (n=17, 13.6%), orthopedic and injury (16, 12.8%) and pain (16, 12.8%). Significantly more enrollees with an ED claim were diagnosed with lymphoma (p < 0.01), lived in rural areas (p < 0.01), and lived in areas with many families living in poverty (p < 0.01). In adjusted models, enrollees with an ED claim reported significantly worse access to care (β −4.83; 95%CI −9.29,−.38; p = 0.03). CONCLUSION: The management of urgent care concerns for adults with hematologic malignancies remains an important clinical and quality improvement imperative. Further study is warranted to enhance the management of emergent complications in older adults receiving care for hematologic malignancies, with efforts that enhance coordination of ambulatory oncology care.

Summary Background & aims In hospital nutrition care the difficulty of translating knowledge to action often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awareness of malnutrition, specific local remedial actions rarely followed. Thus, reducing the Knowledge-to-action (KTA) gap in nutrition care requires more robust and focused strategies. This study describes the strategy, methods, instruments and experience of developing and implementing nutritionDay 2.0, an audit and feedback intervention that uses quality and economic indicators, feedback, benchmarking and self-defined action strategies to reduce the KTA gap in hospital nutrition care. Methods We used an evidence based multi-professional mixed-methods approach to develop and implement nutritionDay 2.0 This audit and feedback intervention is driven by a Knowledge-to-Action framework complemented with robust stakeholder analysis. Further evidence was synthesized from the literature, online surveys, a pilot study, World Cafes and individual expert feedback involving international health care professionals, nutrition care scientists and patients. Results The process of developing and implementing nutritionDay 2.0 over three years resulted in a new audit questionnaire based on 36 nutrition care quality and economic indicators at hospital, unit and patient levels, a new action-oriented feedback and benchmarking report and a unit-level personalizable action plan template. The evaluation of nutritionDay 2.0 is ongoing and will include satisfaction and utility of nutritionDay 2.0 tools and short-, mid- and long-term effects on the KTA gap. Conclusion In clinical practice, nutritionDay 2.0 has the potential to promote behavioural and practice changes and improve hospital nutrition care outcomes. In research, the data generated advances knowledge about institutional malnutrition and quality of hospital nutrition care. The ongoing evaluation of the initiative will reveal how far the KTA gap in hospital nutrition care was addressed and facilitate the understanding of the mechanisms needed for successful audit and feedback. Trial registration Registration in clinicaltrials.gov: Identifier: NCT02820246.

Objectives The COVID-19 pandemic has had major implications for the United States healthcare system. This survey study sought to identify practice changes, understand current personal protection equipment (PPE) use, and determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers versus low case numbers. Methods A fourteen-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons’ current practice was sent to 365 vascular surgeons across the country via REDCap from 4/14/2020 to 4/21/2020 with responses closed on 4/23/2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania and California) differed from those with lower case numbers (all other states). Results A total of 121 vascular surgeon responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between high case and low COVID case states (p=0.285). High case states were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case types did not differ. Most attendings work with residents (90.8%) and limited their exposure to procedures on suspected/confirmed COVID-19 cases (56.0%). Thirty-eight percent of attendings have been redeployed within the hospital to a vascular access service, and/or other service outside of vascular surgery. This was more frequent in high case volume states compared to low case volume states (p=0.039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons feel that they do not have adequate PPE to perform clinical their duties. Conclusion The initial response to the COVID-19 pandemic has resulted in reduced elective cases with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty, however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey., ARTICLE HIGHLIGHTS: Type of research: Nationwide survey of attending vascular surgeons Key Finding: Most of the 121 vascular attendings who responded are limiting resident involvement in COVID-19 positive cases, 38% of attendings have been redeployed to services other than traditional vascular surgery, such as the ICU and vascular access service, and 71% are reusing personal protective equipment (PPE). Twenty-one percent of vascular surgeons do not feel they have adequate access to PPE. Take Home Message: There have been major changes to vascular surgery practice during the COVID-19 pandemic.

Purpose The purpose of this pre-post survey study was to assess the effect of the Patient SafetyNet system (Masimo Corp, Irvine, CA) on postoperative respiratory evaluation by nurses in general wards. Patient SafetyNet is a wireless monitoring system that evaluates respiratory rate and percutaneous oxygen saturation. Design Survey of nurses at a single medical center. Methods Staff nurses (n = 75) were queried using a questionnaire asking about methods and problems of postoperative respiratory monitoring, usefulness of this system, and suggestions about suitable cases of this system. Findings A total of 75 questionnaires were completed and returned. The nurses reported that central/remote (89.3%) or continuous (98.7%) monitoring was useful in the postquestionnaire. Moreover, the average frequency of clinical examination was reduced from 11.0 ± 2.3 to 5.1 ± 1.3. Using the Patient SafetyNet system led to a reported 61.3% reduction in nursing workload related to respiratory assessment postoperatively. Conclusions Continuous monitoring of respiratory rate and percutaneous oxygen saturation after general anesthesia is recommended for patients' safety. Moreover, Patient SafetyNet can decrease the number of physical assessments of respiratory status for postoperative patients in the general wards, resulting in reduction of nurse's workload.

Background and aims The first hybrid artificial pancreas (AP) systems with insulin only (mono-hormonal) have recently reached the market while next generations systems are under development including those with glucagon addition (bi-hormonal). Understanding the expectations and impressions of future potential users about AP systems is important for optimal use of this clinically effective emerging technology. Methods and results An online survey about AP systems which consisted of 50 questions was addressed to people with type 1 diabetes in the province of Quebec, Canada. Surveys were completed by 123 respondents with type 1 diabetes (54% women, mean (SD) age 40.2 (14.4) y.o., diabetes duration 23.7 (14.1) years, 58% insulin pump users and 43% glucose sensor users). Of the respondents, 91% understood how AP systems work, 79% trusted them with correct insulin dosing, 73% were willing to replace their current treatment with AP and 80% expected improvement in quality of life. Anxiety about letting an algorithm control their glucose levels was expressed by 18% while the option of ignoring or modifying AP instructions was favoured by 88%. As for bi-hormonal AP systems, 83% of respondents thought they would be useful to further reduce hypoglycemic risks. Conclusions Overall, respondents expressed positive views about AP systems use and high expectations for a better quality of life, glycemic control and hypoglycemia reduction. Data from this survey could be useful to health care professionals and developers of AP systems.

Summary Background No national epidemiological investigations have been conducted on several aspects of cleft lip and palate surgery. Methods The study was performed using the data of 5727 people who underwent cleft lip and palate surgery during the 6-year period from 2013 to 2018 archived by the National Health Information Database (NHID) of the Health Insurance Review and Assessment Service. Disease and operation codes were utilized for the analysis. Results Most patients underwent surgery during the first 5 years of life. The number of operations per patient remained almost constant during the study period, but hospital costs per patient gradually increased. When hospital costs per patient were subdivided by institution type, they were found to have steadily increased on an annual basis at all types with the exception of hospital .Since 2016, average hospital stay per operation decreased slightly, but the number of outpatient visits tended to increase. Conclusions Accessibility to tertiary hospitals has improved and patients increasingly choose to be treated at larger hospitals in metropolitan areas. Furthermore, these tendencies are expected to be maintained. Despite reductions in hospitalization stays, the cost of treatment, including operation costs, have increasing considerably. Changes in the insurance system are required to reduce financial burdens imposed on patients and on the National Health Insurance Service.

Nephroblastoma or Wilms tumor, a common embryonal tumor in children, can occasionally occur in adults. The survival of patients older than 18 years is reported to be significantly inferior to that of pediatric patients. Establishing a diagnosis for these rare tumors can be challenging for both clinicians and pathologists, who are not accustomed to considering Wilms tumor as a potential differential in adults. This leads to misdiagnosis and a subsequent delay in the initiation of appropriate therapy. The standard of care is not well established for Wilms tumors in adults. We provide here a comprehensive review of the international literature on the subject with the current management protocols in France. We also propose the need of strong inter-disciplinary collaboration between surgeons, pathologists, and medical and pediatric oncologists for increasing knowledge and formulating treatment strategies for these rare tumors. Homogenous guidelines for treating adults with Wilms tumors have been proposed for all patients in France.

Routine intensive care unit (ICU) utilization for patients with initially stable non-ST segment elevation myocardial infarction is not associated with improved short- or long-term patient outcomes; however, the association with patient experience has not been reported. Using Hospital Consumer Assessment of Healthcare Providers and Systems patient survey data linked to ICU use data from the National Cardiovascular Data Registry, we found no association between hospital-level ICU utilization and metrics of patient experience, including communication, staff responsiveness, and overall satisfaction.

Objective To describe the status of and identify factors associated with physical activity promotion by podiatrists. Design Cross sectional survey. Method In 2016−17 Australian podiatrists were invited to complete an online survey. Items assessed by Likert scale included; frequency of assessing and promoting physical activity and podiatrists’ intentions, attitudes, social norms, confidence, barriers, role beliefs and perceived knowledge and skills regarding the promotion of physical activity. Data were analysed using descriptive statistics, exploratory factor analysis and structural equation modelling. Results Of 316 respondents, 62% reported always/or often giving general and 39% specific physical activity advice. Attitudes to physical activity promotion were mostly positive and 83% agreed it was part of their role. Many believed they have the knowledge 62%) and skills to promote physical activity. Most podiatrists were confident to carry out basic physical activity promotion activities (83%), but fewer were confident assessing physical activity levels (54%), providing specific advice (47%), monitoring patient physical activity levels (49%) and carrying out physical activity counselling (41%). Modelling revealed intention to promote physical activity was most strongly influenced by experiential beliefs (β = 0.35, 95%CI 0.20−0.51) and instrumental beliefs (β = 0.27, 95%CI 0.15−0.40), whereas physical activity promotion was influenced by intention (β = 0.45, 95%CI 0.35−0.55) and behavioural control (β = 0.43, 95%CI 0.33−0.53). Conclusion Physical activity promotion is feasible and regularly practiced in the podiatry setting, however current practice appears suboptimal. Attitudes and behavioural control appear influential in engagement and deserve consideration when designing strategies to improve delivery in podiatric practice.