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Purpose To advocate perspectives to strengthen existing healthcare systems to prioritize maternal health services amidst and beyond the COVID-19 pandemic in low- and middle income countries. Description COVID-19 directly affects pregnant women causing more severe disease and adverse pregnancy outcomes. The indirect effects due to the monumental COVID-19 response are much worse, increasing maternal and neonatal mortality. Assessment Amidst COVID-19, governments must balance effective COVID-19 response measures while continuing delivery of essential health services. Using the World Health Organization's operational guidelines as a base, countries must conduct contextualized analyses to tailor their operations. Evidence based information on different services and comparative cost-benefits will help decisions on trade-offs. Situational analyses identifying extent and reasons for service disruptions and estimates of impacts using modelling techniques will guide prioritization of services. Ensuring adequate supplies, maintaining core interventions, expanding non-physician workforce and deploying telehealth are some adaptive measures to optimize care. Beyond the COVID-19 pandemic, governments must reinvest in maternal and child health by building more resilient maternal health services supported by political commitment and multisectoral engagement, and with assistance from international partners. Conclusions Multi-sectoral investments providing high-quality care that ensures continuity and available to all segments of the population are needed. A robust primary healthcare system linked to specialist care and accessible to all segments of the population including marginalized subgroups is of paramount importance. Systematic approaches to digital health care solutions to bridge gaps in service is imperative. Future pandemic preparedness programs must include action plans for resilient maternal health services.

Background Heart failure (HF) readmission rates have become an increasingly important quality metric since the advent of the Hospital Readmissions Reduction Program. Despite many well-intentioned efforts to reduce readmissions, clinicians continue to struggle with the problem of high HF readmission rates. Hypothesis HF patients with obstructive sleep apnea (OSA) will have higher burden of rehospitalization and mortality than HF patients without OSA. Methods Our study included 344 patient encounters (among 271 unique patients) with a diagnosis of HF from September 2014 through September 2015. Our primary endpoints were all-cause readmission within 30 and 90 days. Multivariate logistic regression was used to assess the relationship between OSA and readmission when accounting for potential confounders. Results The patients’ were 72 ± 10 years old, and predominantly white (76.2%) and male (99.4%). Among the 344 patient encounters, 247 (71.8%) had diagnosed coronary artery disease, 159 (46.2%) had atrial fibrillation, and 99 (28%) had obstructive sleep apnea (OSA). Notably, patients with OSA had an elevated rate of readmission within 30 days (OSA: 30.3% vs no OSA: 19.6%, P = 0.037) and within 90 days (OSA: 57.6% vs no OSA: 36.3P < 0.01). Patients with OSA had increased risk of readmission within 90 days (odds ratio: 2.38, 95% confidence interval: 1.47-3.83, P < 0.01) even after adjustment for potential confounders of age, race, obesity, diabetes, and chronic obstructive pulmonary disease. Conclusions HF patients with OSA have an elevated rate of readmission compared to the general HF population, particularly within the first 90 days after discharge.

Prolonged periods of family caregiving can induce stress levels that may negatively influence caregiver health. However, the physiologic effect of psychological distress in oncology family caregivers has received little attention. Therefore we aimed to determine longitudinal profiles of inflammatory cytokines (IL-6 and IL-1ra) in neuro-oncology caregivers and identify associations between psychological distress and cytokine levels. Depressive symptoms, anxiety, caregiver burden and blood were collected from 108 adult caregivers at adult patients' diagnosis, 4-, 8-, and 12-months. Trajectory analyses of log transformed cytokine levels were performed. Multiple logistic regression analyses evaluated the impact of psychological distress on cytokine levels. For both cytokines, two distinct populations were identified, neither of which changed over time. High IL-1ra was associated with male caregivers with anxiety (OR = 1.7; 95 %CI 1.06-2.83) and obese caregivers (BMI = 40) who felt burdened due to disrupted schedules (OR = 1.3; 95 %CI 1.02-1.77). Conversely, caregivers with a healthy weight (BMI = 25) who felt burdened due to disrupted schedules were less likely to have high IL-1ra (OR = 0.71; 95 %CI 0.54-0.92). Caregivers ≤30 years old with lower self-esteem from caregiving were 1.16 times (95 %CI 1.04-1.30) more likely to have high IL-6. Analysis demonstrated groups of family caregivers with high and low levels of systemic inflammation and these levels did not change longitudinally over the care trajectory. Poor physical health in family caregivers may have a negative impact on the burden placed on the healthcare system in general and on the well-being of neuro-oncology patients in particular.

Background: Oral cancer is a major public health burden in India ranking third among cancers; about 90% of all oral cancers are oral squamous cell carcinomas (OSCCs). Human papillomavirus (HPV) is a well-established oncogenic agent in the causation of cervical squamous cell carcinoma (SCC) and an important risk factor for oropharyngeal SCC, but the link between HPV and OSCC is inconsistent. Knowledge of HPV profile in the OSCC has positive implications for treatment and prevention strategies. Methods: A case–control study was conducted to determine the prevalence of HPV status in 40 newly diagnosed OSCC cases (24 males; 16 females). Age- and gender-matched controls were recruited from the outpatient clinic of a large teaching hospital in Southern India. A questionnaire was used to ascertain the risk factors for OSCC. Using a cytobrush, epithelial cells were obtained from oral cancer lesions or normal mucosa in cases and controls, respectively. The HPV detection and genotyping were done using a real-time polymerase chain reaction technique. Results: Chewing tobacco was strongly associated with OSCC (odds ratio: 3.6; 95% confidence interval: 1.4–9.7), adjusted for potential confounding factors including smoking and alcohol consumption. All the OSCC cases and controls tested negative for HPV DNA. Conclusions: There is an inconsistency in the prevalence of HPV infection in OSCC in India. The prevalence of HPV in OSCC was nil, so the testing for HPV may be unnecessary. The inconsistency of the positivity of HPV in OSCC may be due to a wide palette of geographic and sociocultural differences that exist in the subcontinent. Further studies are, therefore, needed to evaluate the prevalence of HPV in OSCC in the subcontinent and plan optimal therapeutic strategies.

Background and PurposeThe informal care demands of primary malignant brain tumor (PMBT) patients include unique issues associated with neurological and cognitive symptoms. Existing caregiver needs questionnaires do not include these disease-specific symptoms, which are particularly distressing. Therefore, we have developed the neuro-oncology Caregiver Needs Screen (CNS) and evaluated its psychometric properties.MethodsThe 32-item instrument was developed based on PMBT caregiver interviews (N= 109) and expert review. The CNS was tested along measures of depression, anxiety, burden, and mastery in 122 PMBT caregivers. Principal components analysis was used to examine item properties and internal structure. Internal consistency reliability and construct validity were assessed.ResultsSix subscales were identified with internal consistency ranging between alpha = .653 and .857. Convergent validity was verified by moderate/high correlations between measures of caregiver well-being and CNS scale scores.ConclusionsFindings provide preliminary evidence of reliability and validity for the CNS. This instrument can be useful when assessing caregivers' needs for supportive care.

BACKGROUND: Heart failure (HF) readmission rates have become an increasingly important quality metric since the advent of the Hospital Readmissions Reduction Program. Despite many well‐intentioned efforts to reduce readmissions, clinicians continue to struggle with the problem of high HF readmission rates. HYPOTHESIS: HF patients with obstructive sleep apnea (OSA) will have higher burden of rehospitalization and mortality than HF patients without OSA. METHODS: Our study included 344 patient encounters (among 271 unique patients) with a diagnosis of HF from September 2014 through September 2015. Our primary endpoints were all‐cause readmission within 30 and 90 days. Multivariate logistic regression was used to assess the relationship between OSA and readmission when accounting for potential confounders. RESULTS: The patients’ were 72 ± 10 years old, and predominantly white (76.2%) and male (99.4%). Among the 344 patient encounters, 247 (71.8%) had diagnosed coronary artery disease, 159 (46.2%) had atrial fibrillation, and 99 (28%) had obstructive sleep apnea (OSA). Notably, patients with OSA had an elevated rate of readmission within 30 days (OSA: 30.3% vs no OSA: 19.6%, P = 0.037) and within 90 days (OSA: 57.6% vs no OSA: 36.3P < 0.01). Patients with OSA had increased risk of readmission within 90 days (odds ratio: 2.38, 95% confidence interval: 1.47‐3.83, P < 0.01) even after adjustment for potential confounders of age, race, obesity, diabetes, and chronic obstructive pulmonary disease. CONCLUSIONS: HF patients with OSA have an elevated rate of readmission compared to the general HF population, particularly within the first 90 days after discharge.

More than 70% of the annual global deaths are due to noncommunicable diseases (NCDs), and 80% of these deaths occur in low- and middle-income countries. Most of these deaths are in people

This study was designed to audit nurse assessment and documentation for neuropathic pain in postoperative patients. The audit focused on recorded signs of neuropathic pain in the immediate postoperative period. Nurses were educated on how to screen patients for neuropathic signs using the validated and reliable 7-item DN4. Data were obtained from 450 patient charts from the thoracic, orthopaedic and spinal units. Of the 450 patient charts reviewed, 423 included a record of nurse screening of neuropathic pain signs. Screening by nurses found 24% (n=102) of the patients reported between one and four signs of neuropathic pain within the first 3 days following their surgery. This study demonstrated that the incorporation of the 7-item DN4 neuropathic pain assessment tool within the generic pain chart enabled nurses to regularly screen postoperative patients for signs of neuropathic pain in the immediate postoperative period.

Background Pulmonary hypertension (PH) is common among patients with heart failure (HF) and obstructive sleep apnea (OSA) but little data exists regarding how it influences readmission and mortality Objectives We assessed the hypothesis that the presence and severity of PH in patients with OSA admitted with acute decompensated heart failure (ADHF) are associated with hospital readmission and mortality Methods We retrospectively examined consecutive patients admitted to the hospital for ADHF between September 2014 and September 2015 and identified patients with OSA. For patients admitted multiple times, only the index admission was included. The primary endpoints were readmission for heart failure and all-cause readmission. All-cause mortality was a secondary endpoint. The severity of PH was assessed using transthoracic echocardiography. Estimated pulmonary artery systolic pressures (PASP) were individually verified by a single reviewer. Right atrial pressures were estimated using American Society of Echocardiography guidelines on inferior vena cava diameter. Multivariable Cox proportional-hazards regression was used to assess the relationship between PASP and outcomes Results Of 263 patients admitted for ADHF, 62 (24%) had OSA. Patients were 70±7 years old, predominantly white (77%) and male (100%). Thirty-eight (61%) of the OSA patients had PH classified as PASP>36 mmHg; 11 (18%) had severe PH as classified as PASP >60 mmHg. Of the 38 patients with OSA and PH, 17 (44%) had heart failure with preserved ejection fraction, and 21 (55%) had some degree of right ventricular dysfunction as noted on the echocardiogram report. ADHF+OSA patients with PH were more likely to be readmitted within 90 days than those without PH (55% vs 37%). Over a mean follow-up duration of 15 months, ADHF+OSA patients with PH also had significantly increased risk of mortality (HR=2.74, 95% CI 1.01-7.49, p=0.048) Conclusions Patients with HF and OSA have a high prevalence of PH and right ventricular dysfunction. The presence of PH as estimated by echocardiography is associated with readmission and mortality in these patients. Figure 1

PURPOSE: The purpose of the study was to measure the prevalence of acute neuropathic pain in patients with acute burn injuries and the demographic and clinical characteristics of neuropathic pain in this population. We also evaluated the proportion of patients who received twice-daily evaluation of nurses' documentation of neuropathic pain following introduction of a validated neuropathic pain assessment tool embedded within the pain chart. DESIGN: Retrospective, descriptive study. SUBJECTS AND SETTING: The sample comprised 86 patients with second- and third-degree burn injuries. The research setting was a burn injury unit in a provincial center in British Columbia, Canada. METHODS: Medical records over a 1-year prior following introduction of assessment of neuropathic pain into pain charts were retrospectively reviewed, and data collection focused on evidence of nurses undertaking acute neuropathic pain assessment as well as prevalence of report of acute neuropathic pain signs among this patient group. Neuropathic pain was evaluated twice daily using the Douleur Neuropathique 4, a previously validated neuropathic pain assessment tool. RESULTS: Eighty percent of patients cared for received twice-daily neuropathic pain assessment. The prevalence of patients with neuropathic pain based on the Douleur Neuropathique instrument scores was 42%. Males reported neuropathic signs more than female patients, and patients with a greater than 10% body surface burn had a higher prevalence of neuropathic pain. CONCLUSION: Study findings suggest that patients with acute burn injury are at risk of neuropathic pain. We recommend that nurse assessment of neuropathic pain becomes routine during the acute injury phase. Language: en

There is a paucity of research evaluating the impact of symptom management interventions on increasing family caregiver involvement in symptom management and on caregivers' emotional health. In addition, most caregiver interventions are delivered by a health care professional, which can be costly to implement in clinical practice. The purpose of this study was to determine whether, in patients with solid tumors, a nurse-delivered symptom management intervention was more effective than a coach-led intervention in increasing caregiver involvement in symptom management and improving caregivers' emotional health. Both caregivers and care recipients were recruited for the study. Inclusion criteria for patients were ≥40 years of age, English speaking, cognitively intact, and having a diagnosis of stage III or IV tumor. Dyads were randomized to a nurse-delivered symptom management intervention (N = 88) versus the coach-led group (N = 81). Data were collected via telephone interviews at baseline, 10, and 16 weeks. There was no significant main effect of the problem-solving intervention on symptom assistance at 10 weeks, but there were two significant interactions, between trial arm and depressive symptoms and between baseline assistance with symptoms and relationship to the patient. Caregivers with lower depressive symptoms were more likely (OR = 1.99, 95% CI = 1.45–2.76) to provide assistance at 10 weeks if they received the nurse-delivered intervention. Spousal (versus non-spouses) caregivers who provided assistance at baseline were less likely to provide assistance at 10 weeks (OR = 0.58, 95% CI 0.36–0.94). No significant trial arm effects were found on caregiver emotional health, but assistance with greater number of symptoms was associated with worse caregiver depressive symptoms (p

The ability of emergency medical services (EMS) providers to offer an alternative means of nonemergent transport for patients with minor medical complaints is a rarely sanctioned concept in U.S. EMS systems.To prospectively determine if paramedics using transport guidelines can identify patients with minor medical problems who can be safely transported by a nonmedical alternative transport mechanism (taxi).Paramedics in the city of Norfolk, Virginia, who had more than one year of experience and who had completed the study orientation course were eligible to enroll subjects in the study. Predetermined alternative transport exclusion criteria as well as inclusion guidelines were provided to paramedics. After on-scene evaluation, paramedics identified subjects who met the enrollment criteria and were deemed safe for emergent ambulance transport. Enrolled subjects were provided a prepaid taxi voucher, which allowed for transport to the closest emergency department (ED). Patients who refused study participation were transported to the ED by ambulance.Ninety-three subjects were enrolled and transported to the ED via taxi. Eleven patients identified by EMS as meeting enrollment criteria refused study participation. The average time from taxi dispatch to ED triage was 43 minutes (95% confidence interval [CI] = 38 to 48). Nine (10%) subjects transported by taxi were ultimately admitted to the hospital. None of the study participants required ED blood transfusions or emergent procedures or suffered an adverse event that could be directly attributed to the delay in ED arrival by taxi.The ability of EMS to safely triage patients who activate the 9-1-1 system to an alternative transport mechanism remains an unproven concept. Our study adds to the concerns of other published literature that EMS providers underestimate the potential severity of illness.