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A clinical case is described of a patient diagnosed of prostate cancer under treatment with brachytherapy in the last three months. Due to this, the patient presents urinary retention and secondary acute renal failure. This case occurred during the COVID-19 confinament period. Appointments requested by the patient were by telephone and the family doctor, based on each case, decided and scheduled the in-person appointment. Considering this exceptional situation, we want to stress, first of all, the importance of a telephone interview as a filter to decide on the in-person care of the patient. On the other hand, the important role of the ultrasound as a tool to help in the primary care study, which, in the case of this patient, was fundamental to establish the diagnosis and send the patient without delay to the second care level

Introducción: la diabetes mellitus tipo 2 (DM2) es uno de los principales problemas epidemiológicos debido a la naturaleza compleja de la enfermedad. En el plano de atención individual, es necesario llevar a cabo intervenciones nutricionales y promover hábitos de alimentación saludables, utilizando herramientas que permitan una adecuada adherencia a dichas medidas. El objetivo de esta revisión es identificar, a través del análisis de la literatura, las estrategias dietéticas para el control de la DM2 y compararlas según su eficacia para lograr la adherencia del paciente. Métodos: se consultaron las bases de datos Pubmed, Scielo, Google Académico, Ovid y Web of Science con las palabras clave. Resultados: la educación a largo plazo provee conocimientos que el paciente puede utilizar como forma de empoderamiento para la toma de decisiones; sin embargo, estos estudios demostraron cómo la libertad de elegir los alimentos disminuye de manera considerable la adherencia nutricional. La intervención a través de menús establecidos o un control estricto genera buenos resultados a corto plazo, pero apenas logran la consciencia que permitirá al paciente ser responsable de la enfermedad. Este tipo de intervención parece hacer poco para ayudar al individuo a analizar la magnitud e importancia de modificar los hábitos dietéticos de forma saludable a largo plazo. Conclusión: la intervención constante a través de la educación en nutrición es efectiva en la tarea de crear adherencia de los pacientes con DM2 a tratamientos nutricionales a largo plazo. Palabras clave: intervenciones dietéticas, diabetes mellitus, adherencia, alimentos y educación en nutrición, evaluación, eficacia.

Body reactions to drugs can manifest as Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). TEN is the most severe form of cutaneous reactions with an incidence rate of 1-2 per million cases per year. Despite TEN being a critical and life-threatening condition, there is little to no evidence of clear management protocol. We reported a 5-year-old male child who presented with lamotrigine-induced TEN and was successfully treated with intravenous immune globulin (IVIG) with a burn unit care level, while TEN treatment with IVIG is an appropriate approach with predictable good outcomes, burn unit care is also effective in creating highly favorable effects. Upon reviewing the literature, several studies indicate that TEN patients treated with the combination of IVIG and burn unit care lead to decreased levels of morbidity and mortality than when treated with IVIG or burn unit care alone. Therefore, treatment involving both IVIG and burn unit care should be considered for TEN patients.

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

The article discussesthe currentstate of the care level for fetuses, newborns and children with congenital abnormalities of the cardiovascular system. There are considered the features of prenatal diagnostics of heart defects and aspects of the management of pregnancy and childbirth of women with the specified pathology in the fetus. The authors made the analysis of the existing problems in the diagnosis and treatment of congenital heart defects and heart rhythm disorders in children. The article substantiates the introduction of the perinatal cardiology concept and formulates the main issues to be solved at this stage of development.

Background To evaluate the success of plaque reduction after external toothbrushing by instructed laypeople versus dental professionals using either a manual or powered toothbrush. Longitudinal, randomized, parallel-group intervention study in periodontitis patients with reduced oral hygiene quality undergoing anti-infective therapy. Patients were randomly and equally assigned to one of four groups: laypeople using a manual or powered toothbrush or dental professionals using a manual or powered toothbrush. Plaque reduction (Quigley–Hein-Index (QHI), Marginal Plaque Index (MPI)), gingivitis (papilla bleeding index), and cleaning time (seconds) were investigated. Results Thirty-nine patients participated in the study. Neither the choice of toothbrush (p = 0.399) nor the use of a dental professional (p = 0.790) had a significant influence on plaque levels achieved. However, multivariate modeling indicated statistically significant differences in the external cleaning time between brushing groups, with longer time required by laypeople (p = 0.002) and longer use of the powered toothbrush (p = 0.024). Conclusion When the ability to carry out personal oral hygiene is reduced, external brushing by dental professionals or instructed laypeople who meet previously defined criteria such as sufficient personal oral hygiene at home could help to fill the emerging dental care gap. A combination of oral hygiene approaches adapted to the individual needs of the patients in need of external help is necessary for optimum oral hygiene. Trial registration: German Clinical Trials register (https://www.germanctr.de; number DRKS00018779; date of registration 04/11/2019).

BackgroundHigh prevalence of thrombotic events in severely ill COVID-19 patients have been reported. Pulmonary embolism as well as microembolization of vital organs may in these individuals be direct causes of death. The identification of patients at high risk of developing thrombosis may lead to targeted, more effective prophylactic treatment.ObjectivesTo test whether Rotational Thromboelastometry (ROTEM) indicates hypercoagulopathy in COVID-19 patients, and whether patients with severe disease have a more pronounced hypercoagulopathy compared with less severely ill patients.MethodsThe study was designed as a prospective observational study where COVID-19 patients over 18 years admitted to hospital were eligible for inclusion. Patients were divided into two groups depending on care level: 1) regular wards or 2) wards with specialized ventilation support. ROTEM was taken after admission and the data were compared with ROTEM in healthy controls.ResultsThe ROTEM variables Maximum Clot Firmness (EXTEM-/FIBTEM-MCF) were higher in COVID-19 patients compared with healthy controls (pConclusionROTEM variables were significantly different in COVID-19 patients early after admission compared with healthy controls. This pattern was more pronounced in patients with increased disease severity, suggesting that ROTEM-analysis may be useful to predict thromboembolic complications in these patients.

The aim of this study was to evaluate the effect of an oral care intervention program on the incidence of pneumonia and fever as a surrogate endpoint. In addition, we tried to determine the oral care risk factors for the incidence of fever. We provided an oral care program for the elderly at one private nursing home in July 2013. The maximum capacity of the nursing home was 60 residents. The body temperatures of all residents were measured twice a day and were summarized as the incidence of fever over a one-month period, which was used as the dependent variable. The residents’ life conditions, number of teeth, and prescribed diet were used as independent variables. The factors that affected the incidence of fever were the number of remaining teeth, a prescribed diet of sliced food, the meal care level, and the oralCandidalevels. These risk factors affected the incidence of fever independently or interactively with oral care. Some risk factors for the incidence of fever were enhanced by the oral care program. It is important to evaluate and control these factors before the implementation of an oral care program.

Background Little is known about clinical factors associated with undetectable pneumonic shadows on chest radiographs (CRs) for diagnosing pneumonia in the primary care setting. Methods A retrospective assessment of CRs was conducted to compare chest computed tomography (CT) images of patients admitted to Kesennuma City Motoyoshi Municipal Hospital who were diagnosed with pneumonia from April 2014 to June 2016. Results Eighty‐three patients were included, and their average age was 83.8 years. Sixty‐eight patients (81.9%) were officially certified as requiring long‐term care or support. Twenty‐nine of the 83 patients (34.9%) had either negative or normal findings on CRs, and positive findings consistent with pneumonia on CT. There were no significant differences in gender, age, cardiothoracic ratio on CR, or severity between the CR‐negative and CR‐positive groups. The proportion of negative CRs was significantly higher in patients with certified care level 5 under the long‐term care system in Japan and tube feeding. Conclusion The failure rate of CRs for detecting pneumonic shadows was significantly higher in patients with certified care level 5 and tube feeding.

By 2010, on the background of the steady increase in the incidence of malignant tumors in the Vladimir area, primary oncological care level worked inefficiently. Condition of material and technical base of the Vladimir Regional Clinical Oncological Dispensary was also unsatisfactory. All these problems required solution in the form of the National Oncology Program realization in the region. The National Oncological Program has begun to work in the Vladimir region since 2011. Target indicators of the oncological program implementation by 2015 were established. They are: Increase of 5-year survival value of patients with malignant tumors after diagnosis date to 51.4%; Increase the number of malignant tumors early detection cases at the I–II stages up to 51%; Decrease the mortality rate of working age population to 99 per 100 000; Decrease of mortality within one year from the first time of cancer diagnosis to 27%. The following main objectives such as radically improved the material and technical base of oncology dispensary; modern methods of prevention, diagnosis and patients treatment improvement and introduction; the system providing population cancer care focused on the cancer early detection and the specialized combined antitumor treatment provision are realized in order to achieve these goals. The implementation of the tasks allowed to achieve positive dynamics of Vladimir region population cancer care indicators. All the main targets of the National Oncology Program for the Vladimir region were achieved successfully. Implementation of the National Oncology Program has had an extremely positive effect on the cancer services development of, as well as for the health of the entire population of the Vladimir region.

Background: As a result of well-publicized studies, the nonsurgical antibiotic therapy of uncomplicated acute appendicitis has been propagated since 2006. A final assessment regarding efficiency and long-term results is not possible; however, nonoperative therapy of acute appendicitis is actually being discussed more diversely and receives a lot of attention. It is still unknown how far this therapy has found its way into everyday clinical care. Methods: An online questionnaire was sent to 1,400 randomly selected specialists for general/visceral surgery in Germany. Representativeness was achieved by a preselection according to the geographical origin and the care level of the hospitals. Results: 14% of surgeons stated that they methodically treat appendicitis conservatively. 38.1% do so in exceptional cases, while 48.8% reject this therapy. For methodically use, sonography or computed tomography is demanded beforehand. Nonoperative therapy is performed more often in metropolitan areas and maximum-care/university hospitals. Patients’ request for antibiotic therapy is an important factor for conservative treatment. The main argument against this therapy is “medical doubts.” 26% of the surgeons would treat their own appendicitis conservatively. There are distinct associations between the application of conservative therapy, satisfaction with it, and expectations about future development. The response rate was 19.9%. Conclusion: The nonoperative antibiotic therapy of appendicitis is part of clinical practice in Germany. There are differences in preconditions as well as in the acceptance of this therapeutic option with a high proportion of general rejection.

Background Paediatric High Dependency Units (PHDU) specialize in the safe and optimal care of children requiring more close observation and intervention than can be provided on the general ward. Aims 1. To analyze the patient characteristics, seasonal trends, bed occupancy rate and length of stay (LOS) of regional PHDU. 2. To develop a demand model for PHDU based on an annual regional birth rate and a childhood population ( Methods Bed occupancy analysis of PHDU (critical care level II) at University Hospital Limerick (UHL) was conducted. Daily assessment records covering over nine years (2010 to 2019) was used in which patient information indicating age, gender, symptom/signs at presentation along with the management received in PHDU were obtained. Additionally, a recorded location for admission/discharge, date and time of admission and discharge and transfer to tertiary centres was documented. Data was verified with computerized hospital inpatient enquiry (HIPE) and analyzed using SPSS. Demand modelling based on birth cohort and childhood population of the region was determined. UL Hospital group research and ethics committee approved the study. Results Over our study period annual mean general admission rate of 117 to PHDU was observed. Respiratory and Neurological presentations were the most common morbidities (32% and 27% respectively) followed by endocrine, sepsis related and surgical. 53% of admissions were male and 46% female with commonest age group was 0-4 years. Median length of stay was 2.3 days. Commonest respiratory morbidity was bronchiolitis and the most frequent acute neurological presentation was prolonged convulsion/status Annual mean rate for additional respiratory support (mostly Nasal CPAP/BiPAP/High Flow Humidified Oxygen) was 28 and that of tertiary care critical care transfers 18. Since the opening of PHDU in Limerick, tertiary care transfers to Dublin decreased by 54% and admissions to adult ICU by 78%. We estimated a mean annual paediatric admission demand of 110 per 100,000 childhood population Conclusion Our review provides strong evidence for rationalization in the development of more PHDU (critical care level II) facilities available at the regional centres. Additionally, our observations highlight the PHDU demand, appropriate equipping and multidisciplinary staff training/competence to safely cater for the critically ill infants and children at regional centres, thus supporting their safe care closer to home with obvious health economic and societal benefits.

Background The association between oral health and malnutrition has been investigated in detail. The nutrition of elderly subjects in residential care homes is determined by caregivers, dietitians or nutritionists and managed by changing the consistency of their supplied food. However, few reports have described the relationship between oral condition and supplied food consistency. The objective of this study was to determine dentition status and care levels that correlate with supplied food consistency among elderly residents of care facilities. In addition, we estimated the care level at which ordinary food consistency can be supplied by caregivers who cannot diagnose dental status. Method Several factors, including dentition, wearing removable dentures, meals categorized as ordinary or processed (sliced, mashed, or liquefied), and care levels according to the Japanese standardized care-needs certification system were investigated in 276 elderly residents (male, n = 56; female, n = 220; mean age, 87.68 ± 5.94 years) of 12 fee-based care facilities. Results The results of this study showed that care levels were significantly correlated with the consistency of the food supplied to the residents. When supplied food consistency was categorized as ordinary or processed, the number of remaining teeth and the number of tooth contact pairs, either natural or artificial, were statistically significant. From logistic regression analysis, it was determined that the numbers of tooth contact pairs were statistically significant among residents requiring high levels of care. Conclusion The number of tooth contact pairs, either natural or artificial, was one of the contributing factors for deciding supplied food consistency among elderly residents of care facilities. Elderly residents requiring less than care level 3 should have ordinary meals. Electronic supplementary material The online version of this article (10.1186/s12903-019-0770-0) contains supplementary material, which is available to authorized users.

Objetivo: evaluar la asociación entre estado nutricional y fragilidad en adultos mayores con diabetes mellitus tipo 2 (dm2). Métodos: se realizó un estudio transversal, analítico; participaron 128 adultos mayores de 64 años adscritos a la Unidad de Medicina Familiar (umf) no. 75 del Instituto Mexicano del Seguro Social (imss), durante el año 2019; para la recolección de los datos se utilizó una cédula de identificación Mini Nutritional Assessment (mna) y el cuestionario frail para fragilidad. Los resultados se muestran en frecuencias y porcentajes, para determinar la asociación entre el estado nutricional y fragilidad se utilizó la prueba estadística χ2; considerando significativo un valor de p ≤ 0.05. Resultados: 66.4% de participantes fueron mujeres, 33.6% hombres. La media de edad fue de 74.43 años. Se determinó asociación entre estado nutricional y fragilidad (p=0.000); de los 128 adultos mayores que participaron 35.2% fue frágil, 43.8%, prefrágil y 21.1%, robusto. 15.6% tuvo malnutrición, 43.8%, riesgo de malnutrición y 40.6% se encontraba normal. Conclusión: se demostró la existencia de asociación entre el estado nutricional y fragilidad, por lo que es importante promover estrategias que favorezcan la prevención y detección oportunas de estas entidades que afectan a los adultos mayores desde el primer nivel de atención.

The Targeted Training Intervention 360 (TTI 360) program, led by the Alzheimer’s Association, aims to improve quality of care for persons with dementia (PWD) living in Iowa long-term care communities. TTI provides training to administrators (n=10) and direct care professionals (n=45) at 10 participating facilities in Iowa. TTI employs the Experiential Model of Dementia, which focuses on the unmet needs of PWD to increase person-centered care. Data were collected from a pre-test given at the training sessions. An organization’s patient-centered care level was measured using the Person Centered Care Assessment tool (P-CAT). Administrators and their employees were asked to decide the degree to which they believed the statements corresponded to their own experiences within the organization. Participants were split in to three groups for purposes of data analysis: -direct care professionals, directors of nursing, and administrators. An analysis of variance model revealed that administrators endorsed significantly greater person-centered care support (Mean = 48) compared to direct care professionals (M = 42; p=.002). Perceptions of person-centered care were positively related to CMS rating. The results demonstrate that the participating administrators may be disconnected from the reality of care on the ground level of their organizations. Methods that are used to bolster person-centered care and improve the quality of care will be discussed.

Background In recent years German long-term care insurance coverage has gradually been extended to include services for people with limitations in daily living skills. Until now, however, it was unclear who exactly people with limited daily living skills are. Aim The study aimed to characterize people with limited daily living skills who use additional support services as defined by § 45b of the Social Services Code XI (SGB XI). Material and methods This study was based on a survey of 1284 people with limited daily living skills who used additional support services (§ 45b SGB XI). The data were analyzed descriptively. Results The average recipient was 81 years old, mainly in care level I and the majority of them were exclusively cared for by relatives. Of these recipients 61 % were diagnosed with dementia, 73.4 % had medium cognitive impairments while more than half could no longer carry out the instrumental activities of daily living (IADL). Conclusion Statistics on people with limited daily living skills should be included in publications and reports so that the need for care and assistance can be estimated more precisely.

We enforced the construction of a community rehabilitation network for the autonomous rehabilitation of the disabled elderly by the official grant. We distributed the prepared manual and devices developed for subjects in order to perform the rehabilitation exercises. 47 disabled elderly 13 Aftereffect of cerebrovascular accident, 9 hemiplegia left, 3 hemiplegia left and one another), 8 knee osteoarthritis, 7 lumbar spinal stenosis and 19 others were involved as subjects. The change of a body situation depended on the Long-Term Care Insurance Survey (LTCIS) including the Degree of Independent Living for the Disabled Elderly (DILDE) was analyzed with changes in the level of care. As a result, the sitting ability with both feet on Ground has improved significantly (P

Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed.Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction,90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χNo significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p0.001) than H.Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.

Background Diminished oral health of the institutionalized elderly has frequently been reported. This is not only of significance with regard to nutrition and general health, but it can also affect oral health-related quality of life. This paper evaluates the effects of oral and general conditions on oral health-related quality of life for the institutionalized elderly, as measured by the Geriatric Oral Health Assessment Index (GOHAI). Materials and Methods Ninety-four residents of four long-term care homes in southern Germany agreed to participate in this study, and interviews were conducted using the GOHAI questionnaire. The Revised Oral Health Assessment Guide was applied to allocate participants into two groups: satisfactory oral health and poor oral health. To evaluate the effects of age, gender, number of chronic diseases, frequently taken drugs, care level, Mini-Mental State Examination score, periodontitis (for participants with their own teeth), pressures caused by prostheses, and type of denture worn, a linear regression model with the total GOHAI score was calculated with these determinants. Results The mean ± SD GOHAI score was 53.3 ± 6.2 in the satisfactory oral health group and 48.7 ± 7.3 in the poor oral health group. Statistical analysis showed that the GOHAI scores were significantly different in satisfactory oral health and poor oral health groups (P = 0.030) and were affected by care level (P = 0.008) and type of dentures worn (P = 0.006). Conclusions Within the limitations of this study, it can be concluded that oral health-related quality of life of the institutionalized elderly is low and is positively associated with better oral health.

Background and Objectives: The study was performed to investigate the status of osteoporosis for S electronics workers in H hospital of G city form April 21 to May 31 2008. Material and Method: The result of this research is following. Results: As results of osteoporosis analysis based on general characteristic, for men, something of 21 was the most frequent and osteoporosis of 13 was the second most frequent, and for women, good of 12 was the most frequent and care was the second most. The results concludes that men have more problems with osteoporosis that women have. In age of 40 years or more, care level of 24(88.9%) was the most frequent and good level of 15 people was the second most. This result concludes that age of 40 year is target subjects for care. In position, senior has 14 people who have care level(42.4%) and 8 people(24.2%)of osteoporosis level. The result concludes than the senior has more osteoporosis than the employ has. Conclusion: In conclusion, the age, position, weight are related to osteoporosis.

Pediatric cancer is becoming increasingly important in low-/middle-income countries (LMICs), due to the improvement in controlling communicable diseases, decrease infant, and early childhood mortalities associated with infection and malnutrition. Worldwide, although much improvement was encountered in many pediatric tumors particularly acute leukemia that represents the commonest type of cancer in children, this was not so obvious in CNS tumors, the second most common tumor type. Slow advances have been achieved to improve treatment end results in pediatric neuro-oncology. This was largely related to disease under diagnosis, incorrect clinical assessment, improper staging, and lack of the availability of appropriate radiologic, neurosurgical, and radiotherapeutic services in LMICs. Moreover, the need for multidisciplinary team working together to embalmment unified approved management guidelines, highly specific care level within a widely accepted quality control measures are of utmost importance to raise the treatment outcome levels to that of high-income countries (HICs). Much effort is needed in LMICs to improve the management of pediatric CNS tumors, decrease the gap, and reach good results already attained by the dedicated centers in HICs. There are many international organizations and societies that can and are willing to help in this matter. In this chapter, an illustration of the obstacles faced by LMIC neuro-oncologists will be discussed. The different ways and procedures are recommended to improve the general situation to attain good results similar to that in HICs.

The GE QuietCare® passive monitoring system uses advanced motion sensor technology that learns the daily living patterns of senior community residents and sends alerts when certain out-of-the-ordinary events occur. This study compared falls, hospitalizations, care level changes, and resident attrition between two similar assisted living facilities where one facility adopted the QuietCare® monitoring system and the other did not over a 12-month period. Average falls per week were significantly lower in the QuietCare® facility than the control facility. There was also a trend toward fewer weekly hospitalizations in the QuietCare® facility. There was higher resident retention at the QuietCare® facility. This study provides evidence of direct benefits to both the resident and the facility for the use of QuietCare®. There was a significant reduction in the number of falls, as well as a general facility performance improvement measured by care level consistency and higher resident retention rates.

Strokes in childhood and adolescence often cause various disabilities and problems which result in extensive treatment measures. From the data of 86 sets of parents, we have analysed the neurological symptoms, cognitive disabilities and behavioural problems of patients with stroke in childhood or adolescence, about their treatment options and the time-based and financial burden of their parents. Especially children with perinatal stroke have severe impairments in motor functions, language development, execution of functions, attention, and social behaviour. They receive ambulant therapies, care levels and handicapped ID more often. Inpatient rehabilitation was received by 41.9 %, outpatient therapies by 96.5 % of the children; 39.5 % have a care level, and 61.6 % a handicapped ID. The parents invest 7 hours 20 minutes a week in therapies for their children. Their average financial burden amounts 125.44 € per month. The existing treatments should be enlarged, especially in kindergartens and schools. The present financial compensation due to the aliments should be revised.

Introduction. Physical problems of leprosy clients such as leprosy wounds and disability resulting negative publicperception (stigma) for the clients. The purpose of this study was to analyze the effect of the intervention Coaching: RGOto the level of self-care of leprosy clients. Method. This study used an experimental design with one group pretest andposttest. The study was conducted during one month in leprosy clients undergoing rehabilitation through community.Eighteen (18) leprosy clients in Puskesmas Tempurejo and Jenggawah selected as respondents using simple randomsampling. Result. The results showed that the level of self care before the RGO intervention the majority (83.3%) ofclients was dependent. After the intervention, the majority of clients (61.1%) experience independence on performingself care. Analysis using frequency distribution and kendall 's tau showed the effect of coaching on the level of self-careindependence of the leprosy clients (p 0.000; α 0.05). Discussion. Leprosy clients require a gradual and regular exercisetwice daily in the treatment of eyes, hands, and feet by doing soak, rub, and topical to prevent the disability.Keywords: Coaching, Leprosy, community-based rehabilitation

Aim: To develop a Japanese version of the Care Planning Assessment Tool (J-CPAT), originally developed in Australia as a comprehensive assessment of people with dementia. Methods: The process of adapting the CPAT into Japanese included translation into Japanese, assessment of item comprehension, and a validity and reliability study. The J-CPAT is composed of eight domains: Communication, physical problems, self-help skills, confusion, behaviour, social interaction, psychiatric observations and carer dependency. The participants were 199 aged care clients. Measures were the J-CPAT, Mini-Mental State Examination (MMSE) and Care Levels used in the Long-term Care Insurance scheme. Results: Cronbach's alpha values in each J-CPAT domain were 0.74–0.95. The correlation coefficient between the score of Confusion and MMSE was −0.90, and those between physical problems, self-help skills, carer dependency in the J-CPAT, and care level were 0.70, 0.75 and 0.67. Conclusions: The J-CPAT appears to be a reliable and valid tool for care planning in Japan.

a b s t r a c t Objective: To characterize rheumatoid arthritis patients seen in rheumatology units at different health care levels. Material and methods: Questionnaire and clinical examination of rheumatoid arthritis patients seen as outpatients in rheumatology units from primary care, county hospitals and reference hospitals. Demographic, social, labor, and disease data were collected. Statistical study included a description of the variables and a multiple correspondence analysis to define patient profiles. Results: Eight hundred and twelve patients with rheumatoid arthritis were included. There were significant differences in patient profiles at the different care level. In primary care, patients were older, with basic studies, and with short duration and generally mild rheumatoid arthritis. In local hospitals the typical patient was a man, qualified worker, with low income, and an erosive disease with extraarticular manifestations. At reference hospitals prevailing patients were young women with a long duration disease and requiring biological therapy. Conclusion: There are significant differences in rheumatoid arthritis patient profiles at different health care levels.

Objective Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. Study Design We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). Results The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. Conclusion Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.

The purpose of this study was to clarify the effects of dementia based on the changes of independence conditions targeting the home-care elderly classified as Care level 1 of care needs or support. The care managers entered the basic information and assessment including oral health care for them. The independence level and other aspects of the elderly with and without dementia were examined comparatively for eight weeks. The results were as follows: 1. The highest independence level was observed for oral health care of the elderly without dementia, and it remained at the highest level for eight weeks. 2. Almost all independence levels of the elderly with dementia were significantly lower than those without dementia. 3. The willingness of the elderly without dementia was high among all areas, it was the highest of oral health care. A significant difference was observed between those with and without dementia. 4. As for cooperation from family members, the lowest value was oral health care. It is suggested that the elderly requiring home-based long-term light care or support have a high independence level concerning oral health care. The willingness toward oral health care of the elderly with mild dementia was still high. The elderly with dementia were less independent regarding oral health care. Moreover, an increasing number of elderly people live by themselves, and do not expect support from their families. Active intervention by experts is necessary to improve their independence concerning oral health care.

In this paper an evaluation approach to assess the co-ordination of supportive community cancer care is presented. The aim of the study was to identify current gaps in co-ordination of services in a selected region in the province of Ontario, Canada, determine how consistent these gaps were across the province of Ontario, and develop service design considerations for improving the co-ordination of supportive cancer care services in the province of Ontario. The study addressed services required by two populations -clients who had been recently diagnosed and those in the palliative stages of cancer. The evaluation was theory-driven and incorporated evidence from three methods: a systematic literature review, a community case study and a provincial scan. The results revealed the absence of a formal supportive cancer care system and a complex community care system. Supportive cancer care was shown to be delivered by a range of generalist programs that lacked specialisation in addressing the unique needs of cancer clients. In addition, there was no clear evidence of leadership for co-ordinating supportive cancer care, where client care was most often provided by multiple programs at any given point in time. The study generated recommendations to improve co-ordination of supportive cancer care at both the administrative as well as direct care level.

BACKGROUND: The efficacy and precision of dispatching right ambulance to right patient demands a proper decision-making. Wrong decisions may lead to overloading of emergency departments and shortage of ambulances. The aim of this study was to evaluate and improve the process of prehospital resource allocation conducted by a Swedish ambulance dispatch center.METHODS: A team of three experienced ambulance and dispatch nurses evaluated the decisions made by the dispatch center. The method chosen was “Action Research” divided into five actions during 76 days. In the first action, the team listened passively to the calls. The team gradually increased its involvement in the process of decision-making during the actions.RESULTS: During the actions, specific keywords indicating a need for evaluation were identified. The results showed a need to change the primary decisions in 486 cases out of 24,800 calls (2%). The most common measure after an evaluation was to change an ordinary ambulance transportation to an assessment vehicle staffed by a nurse or a physician who would select an appropriate care level (hospital vs. primary healthcare).CONCLUSION: This model not only optimized the prehospital resources but also changed the process of decision-making at the dispatch center and improved their staffs’ ability to optimize the allocation of emergency resources.

In the last years prematurity rates have increased, together with the survival rate among premature subjects. In addition now even infants born at 23 weeks of gestational age can survive. However, some studies demonstrate that premature children are more likely to show late disabilities and to be hospitalised during childhood. In Italy the premature childrens’ care level too often depends on the socio-economic status of the Region: central decisions about assistance until the beginning of teenage are yet to be taken. A strict monitoring of pregnancy and of risk factors predisposing to premature birth as well as a careful management of perinatal period should further improve survival and quality of life of these subjects.

Planning for major incidents includes knowledge of and routines for mastering the effects of thermal injury. It is important to realize that such skills are not only needed in large isolated fires but are important in other types of incidents as well because burn injuries may be present among other injuries. When describing modern planning for response to major burn incidents, it is important to be aware that modern burn care has changed significantly as medical progress has been made within this field, especially during the last decades. This implies that modern management of major burn injuries also has changed, which underlines the need for proper planning, management, and training. Addressing such issues, this chapter also describes other facts with implications for burn disaster management. One is that the incidence and prevalence of burns are declining and have been approximately 30% for the last 20 years, and burn care is concomitantly being centralized in many parts of the western world. Consequently, medical staff at different levels of care throughout various countries will have less practical experience in the field of burns. The described changes have implications for the modern management of major burn incidents. Lastly, an increased international cooperation and exchange of ideas have made burn care more global, especially when those injured in recent accidents have been transported between countries over long distances.

Summary Improving hospital operation in terms of quality of care, patient safety and efficiency requires the capacity to routinely analyse patient flow. To that end, a generic data model to represent patient trajectory across various hospital «compartments» (e.g. care units, clinical services, care levels) was developed. To build the model, time intervals during which a patient remains in the same set of compartments (e.g. the same care unit, the same clinical service, the same care level) were first identified for each stay using data extracted from the hospital information system. Each of these time intervals was then split into constant timesegments (i.e. days, hours) and the number of minutes the patient was present in each of them was counted. In addition, an entry flag (or exit flag) was attached to a timesegment if during this time-segment a patient entered (or left) a given compartment. The data model which was implemented on a MySQL-Infobright database using a starjoin schema allows, via basic SQL queries, a large array of analyses and detailed graphic visualisations of patient flow using numerous different time steps (month, weeks, days, weekdays, hours, etc.). By this means it dramatically increases the hospital’s capacity to address patient flow issues and prepare the way for patient flow simulation.

Regionalization of health care for trauma has become commonplace, and the same concept for critically ill medical/surgical patients is developing. Recent evidence suggests that current stabillization measures used by transport teams can be inadequate for this critically ill patient population. In trauma, speed has been considered a necessity to get the patient to a facllity which cannot be carried out to the field, eg, an operating room. For acute medical Illnesses, critical care transport teams can bring intensive care technology to the patient. Accumulating evidence supports the premise that speed of transport is not as important as stabilization before transport, knowledge of hemodynamics during transport, and early use of critical care monitoring systems. Other reports identify the need for initial evaluation and stabilization of critically ill patients by physicians at the critical care level of expertise. Accordingly, critical care transportation teams have evolved, creating new notions of pretransport stabilization not applicable to previous transport systems.

Background A new long-term care insurance system was launched in Japan in April 2000. Objectives We performed the first national survey on special units of psychiatric hospitals for dementia patients to examine whether their disabilities were well reflected in the eligibility assessment. Methods Of all 248 dementia special units of psychiatric hospitals in Japan, 180 units (72.6%) participated in the survey. Five patients were randomly selected in each unit, and we used data of 802 (89.1%) of 900 patients whose care levels were obtained by the primary computer assessment. These patients were assessed using the Mini-Mental State Examination (MMSE), dementia rating scale by Gottfries et al. (1982) (GBS), and Activities of Daily Living (ADL). The mean score (SD) of the MMSE was 9.3 (6.9). Results Multiple regression analysis revealed that the scores of motor function in GBS, ADL, MMSE, and the degree of bedridden explained 73% of the variation of care level. The higher care levels were inversely related to lower MMSE scores. In the group of people who were not bedridden, the MMSE score sharply decreased even though their physical functions were maintained. There were no significant differences in the MMSE scores among the care level 1 and 5 groups except between care level 1 and 3 after controlling for the motor function scores in GBS. Conclusions Our results suggest that care level and cognitive impairment are generally correlated in the primary assessment, but some adjustment measure for cognitive impairment is needed in mildly or moderately physically disabled patients. Copyright © 2001 John Wiley & Sons, Ltd.

ResumenLa Sociedad Española de Medicina Familiar y Comunitaria (semFYC) y la Sociedad Española de Angiología y Cirugía Vascular (SEACV) han elaborado, mediante un grupo de trabajo conjunto, un documento de derivación entre niveles asistenciales de los pacientes con las principales patologías vasculares: enfermedad arterial periférica, insuficiencia venosa y pie diabético. Se han definido las responsabilidades y habilidades requeridas de cada nivel asistencial y también los criterios de derivación mutua, así como los de priorización. La elaboración de este documento consensuado pretende aportar una herramienta eficiente que asegure la continuidad en la asistencia sanitaria, respetando siempre las particularidades y necesidades específicas de cada zona sanitaria.AbstractThe Spanish Society of Family and Community Medicine (semFYC) and the Spanish Society of Angiology and Vascular Surgery (SEACV), through a Joint Working Group, have prepared a document on between care-level referrals of patients with the main vascular diseases; peripheral arterial disease, venous insufficiency, and diabetic foot. The responsibilities and skills required at each care level have been defined, as well as the criteria for mutual referral and how to prioritise them. The preparation of this consensus document attempt to provide an efficient tool that may ensure the continuity of health care, always respecting the specific characteristics and needs of each health care area.

This paper describes an on-line patient classification program operated from each nursing care unit. The patients are evaluated according to CRT screen menus of care needs by the care unit nurses. The program then weights each patient and assigns a care level. Daily summaries of these weights and their attendant staffing levels are available to administrators for guidance and justification in assigning personnel, establishing costs of care, and future planning. The logic and input/output of this program are a joint development between nursing and computer personnel.

Background Increasing incidences of dementia necessitate the improvement of supportive measures for patients suffering from this disease and their proxies. Clinicians without psychiatric backgrounds and others involved in appraising the supportive needs of dementia patients, such as those who allocate nursing insurance, base their appraisals on the ability of patients to perform basic and instrumental activities of daily living (B-ADL, iADL). Our aim was to investigate whether a reduced ability of the patient to perform ADL is sufficient to adequately assess the supportive needs of family caregivers. Methods Cross-sectional baseline data were obtained from dementia patients and their proxies in the context of a nationwide prospective cohort study on non-pharmacological treatment of dementia. To our knowledge, the present study is the first country-wide study to assess patients and proxies in their domestic surroundings (e.g. Mini-Mental State Examination (MMSE) Behave-AD, B-ADL and iADL for patients; Quality of Life (QOL) and depression of the proxy). Results Logistic and linear regression analysis show that the allocation of nursing care allowance provided by German mandatory nursing insurance is associated with scores on the B-ADL- and iADL scales, but not with the severity of behavioural symptoms or the supportive time the proxies spend on caring. However, the severity of cognitive and non-cognitive symptoms of dementia patients, correlate with each other and both parameters correlate with the time the proxy spends on caring. The time spent on caring is associated with an increase in depression and a reduction in the quality of life of the proxy. Conclusions Basic and instrumental activities of daily living do not sufficiently reflect the perceived burden of care experienced by the proxy who has to cope with the imposition of the dementia patients’ behavioural symptoms. When allocating nursing care, patients’ behavioural symptoms should also be taken into consideration, because depressive symptoms of proxies are linked to non-cognitive symptoms in dementia patients. To provide better health care, it is necessary to identify and treat psychiatric symptoms in proxies who care for dementia patients as early as possible.

ObjectivesPatients ≥65 years old represent 30%–50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this study was therefore to describe and compare characteristics of patients’ aged ≥65 years dispositions during AA, including determining changes over time and factors associated with non-conveyance to hospitals.DesignA longitudinal and comparative database study.SettingAmbulance service in a Swedish region.Participants32 085 AAs with patients ≥65 years old during the years 2014, 2016 and 2018. Exclusion criteria: AAs with interhospital patient transfers and lack of patients’ dispositions data.Outcome measuresDependent factors: conveyance and non-conveyance to hospitals. Independent factors: age, sex, symptom, triage level, scene, time, day and season.ResultsThe majority (n=29 060; 90.6%) of patients’ dispositions during AA were conveyance to hospitals. In total, the most common symptoms were circulatory (n=4953; 15.5%) and respiratory (n=4529; 14.1%). A significant increase, pConclusionsThe study demonstrates several patient characteristics, and factors associated with non-conveyance to hospitals, such as age, symptom, triage level, scene, time, day and season. The increasing non-conveyance trend highlights the importance of further studies on optimal care levels for patients ≥65 years old.