Evidence of On-Going Disparate Levels of Care for South Asian Patients with Inflammatory Bowel Disease in the United Kingdom during the Quinquennium 2015–2019

Over the last decade, there have been a number of studies which have documented disparate levels of care in the management of inflammatory bowel disease amongst various minority communities in the UK. Similar findings had previously been described in the USA, where access to biologics has been an issue. In this study, data on admissions to hospital of South Asian and White British patients with inflammatory bowel disease between 2015 and 2019 were collected from 12 National Health Service (NHS) trusts in England, three Health Boards in Wales and two Scottish health organizations using Freedom of Information requests. The analyses of data were based on the assumption that inflammatory bowel disease (IBD) has the same prevalence in the South Asian community and the White British community in the UK. Comparisons were made between the proportion of hospitalised patients who were South Asian and the proportion who were White British in the local community using a z statistic. In Leicester, Bradford, Croydon and Lothian, the proportion of patients from the South Asian community admitted to hospital was significantly greater than the proportion from the local White British community, which is consistent with the greater frequency and severity of the disease in the South Asian community in the UK. However, in Coventry, Wolverhampton, Walsall, Acute Pennine Trust in the north-west of England, Barking, Havering and Redbridge and Glasgow, South Asian patients were significantly under-represented, indicating significant issues with access to hospital-based healthcare for inflammatory bowel disease. This study provides evidence of on-going evidence of disparate levels of care for patients from a South Asian background, with inflammatory bowel disease being underserved by a number of NHS Trusts, Health Boards and comparable organisations. When there is on-going failure to achieve the objectives of the NHS of achieving equality in the delivery of care, it is critical to introduce effective policies which will alter the in-built inertia to change within such organisations.

Flying with a Safety Net: Use of REBOA to Enable Safe Transfer to a Level 1 Trauma Center

Background: Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) during air and ground transport requires coordination among the responding clinical team, transport team, and receiving surgical team. Here, we describe the development of a REBOA transport program in a civilian medical system that demonstrates the value of REBOA as part of the toolkit for safe casualty transport. Methods: The regional REBOA program was developed at St. Anthony Summit Medical Center in a multi-step planning and training process to ensure coordination among the facilities and transport resources during trauma patient care. Retrospective record review was performed on all patients (n=5) that received REBOA for transport from the Level 3 Trauma Center to the Level 1 Trauma Center, since inception of the program in March 2019. Data were gathered from hospital electronic medical records. Results: SASMC has transported five trauma patients under the REBOA program; all successfully arrived at the Level 1 Trauma Center to receive definitive care. The integrated arterial blood pressure monitoring capability in the REBOA catheter provided robust physiologic data to enable data-driven interventions during transport. Conclusion: The REBOA program described here is a model of how REBOA can be used to enable safe transport between levels of care, when, without REBOA, such transport might not be possible. The model is applicable during care of civilian trauma patients and combat casualties, where injured patients are initially treated in a prehospital or Role1/2 environment but require transport to a Level 1 Trauma Center or Role 3+ for definitive care. Keywords: REBOA, non-compressible hemorrhage, patient transport

Clinical Characteristics of Vulnerable Populations Hospitalized and Diagnosed with COVID‑19 during Second Wave in Buenos Aires, Argentina.

There are a few in Argentina publications regarding the presentation of patients with COVID-19 requiring hospitalized and emergency care in vulnerable populations that compares the first and second wave, and it has few reports in developing countries. The objective is to determine whether in the care of vulnerable patients, to succeed against COVID-19, multiple public health tools and interventions necessary to minimize morbidity and mortality. The study is a prospective cohort investigation of 3028 patients during second wave with lab-confirmed COVID-19, who required any of the Health Centers response from April 1, 2021, to June 30, 2021. In a previous publication, our group analyzed the situation of hospitalized patients during the first wave in the same region, "Southeast Network" (SN), Buenos Aires Metropolitan Area (AMBA). SN with 1.8 million inhabitants residing in urban and rural areas. A total of 14 health centers with different levels of care complexity provide care to patients in the region. The information of each patient with COVID-19 evaluated by SN, was incorporated in an Epidemiological Dashboard. The investigation was designed and reported with consideration of observational studies in epidemiology. A total of 57.9% patients were men, and the mean age (SD) was 52.1 (13.5) years. Sixty four percent patients with pre-existing diseases, most frequent hypertension and diabetes, but diabetes, obesity, and cardiovascular disease presented higher risk. A total of 24.7% were hospitalized in Intensive Therapy Unit. The mortality of the cohort was 22.9%. Mortality was higher for patients aged 65 or more, and for those had some pre-existing disease. But, it was a slightly more than double that in the first wave, it is possible mainly due to the fact that more than doubled of patients in Second wave required hospitalization in ITU, compared to First wave. The patients presented greater severity of their medical condition at the time of their hospitalization. These findings were similar to those reported by other authors. Another possible cause of the high number of patients in the period studied is due to the fact that most of the hospitalized population had not been vaccinated. The health system was able to respond to the demand.

Palliative care in the pre-hospital service in Brazil: experiences of health professionals

Background An integrated care network between emergency, specialized and primary care services can prevent repeated hospitalizations and the institutionalized death of terminally ill patients in palliative care (PC). To identify the perception of health professionals regarding the concept of PC and their care experiences with this type of patient in a pre-hospital care (PHC) service in Brazil. Methods Study with a qualitative approach, of interpretative nature, based on the perspective of Ricoeur’s Dialectical Hermeneutics. Results Three central themes emerged out of the professionals’ speeches: (1) unpreparedness of the team, (2) decision making, and (3) dysthanasia. Conclusions It is necessary to invest in professional training associated with PC in the home context and its principles, such as: affirming life and considering death as a normal process not rushing or postponing death; integrating the psychological and spiritual aspects of patient and family care, including grief counseling and improved quality of life, adopting a specific policy for PC that involves all levels of care, including PHC, and adopt a unified information system, as well as more effective procedures that favor the respect for the patients’ will, without generating dissatisfaction to the team and the family.

Nationwide evaluation of the advanced clinical practitioner role in England: a cross-sectional survey

Background and study objectiveIn response to growing pressures on healthcare systems, the advanced clinical practice (ACP) role has been implemented widely in the UK and internationally. In England, ACP is a level of practice applicable across various healthcare professions, who exercise a level of autonomy across four domains, referred to as the four pillars of practice (education, leadership, research and clinical practice). A national framework for ACP was established in 2017 to ensure consistency across the ACP role, however current ACP governance, education and support is yet to be evaluated. This study aimed to analyse data from a national survey of the ACP role to inform the development and improvement of policies relating to ACP in the National Health Service (NHS) in England.DesignA cross-sectional survey with free-text comments.SettingThe survey was distributed across primary and secondary levels of care to three distinct groups in England, including individual ACPs, NHS provider organisations and Trusts and primary care settings.ParticipantsA total of 4365 surveys were returned, from ACP staff (n=4013), NHS provider organisations and Trusts (n=166) and primary care organisations (n=186).ResultsConsiderable variation was found in role titles, scope of practice, job descriptions and educational backgrounds of ACPs. Differing approaches to governance were noted, which led to inconsistent ACP frameworks in some organisations. A further challenge highlighted included committing time to work across the four pillars of advanced practice, particularly the research pillar. ACPs called for improvements in supervision and continuing professional development alongside further support in navigating career pathways.ConclusionsA standardised approach may support ACP workforce development in England and enable ACPs to work across the four pillars of practice. Due to the wide uptake of ACP roles internationally, this study has relevance across professions for global healthcare workforce transformation

Behavioural Challenges Associated With Risk-Adapted Cancer Screening

Cancer screening programmes have a major role in reducing cancer incidence and mortality. Traditional internationally-adopted protocols have been to invite all ‘eligible individuals’ for the same test at the same frequency. However, as highlighted in Cancer Research UK’s 2020 strategic vision, there are opportunities to increase effectiveness and cost-effectiveness, and reduce harms of screening programmes, by making recommendations on the basis of personalised estimates of risk. In some respects, this extends current approaches of providing more intensive levels of care outside screening programmes to individuals at very high risk due to their family history or underlying conditions. However, risk-adapted colorectal cancer screening raises a wide range of questions, not only about how best to change existing programmes but also about the psychological and behavioural effects that these changes might have. Previous studies in other settings provide some important information but remain to be tested and explored further in the context of colorectal screening. Conducting behavioural science research in parallel to clinical research will ensure that risk-adapted screening is understood and accepted by the population that it aims to serve.

Voices from the Lagers in Germany

This paper traces the everyday realities of refugees living in camps in certain federal states of Germany during the ongoing COVID-19 crisis. It provides a systematic analysis of refugees’ testimonies and demonstrates that they have not received similar levels of care and protection as German citizens, and that their movement has become increasingly regulated. Drawing on Achille Mbembe’s notion of ‘necropolitics’, I argue that the German State has treated refugees’ lives as less liveable than those of their own citizens during the pandemic, as was the case before it broke out. Much scholarship has explained the notion of refugee camps in various ways, but there has been less discussion of Lagers (camps) as a site where colonial oppression persists outside the temporal and spatial contexts of former colonies. Data are drawn from archived data sets and testimonies that refugees uploaded to websites of various refugee activist groups.

Age and the City

<p>Social isolation and loneliness affecting a large number of older persons and elderly is a prevalent issue in today’s society. Current older persons and the Baby Boomer generation approaching this age are far more independent than previous generations. Their perception of ‘retirement’ has a negative connotation due to society’s pressures and value placed in remaining independent and useful. The current model of aged care housing, although existing in many forms catered towards different levels of care, is generally seen as a last resort and an acceptance of being dependent on others for day-to-day things. This has led to a trend of ageing in place, in homes which are arguably too big for a single person or couple and often not equipped to adapt to bodily decline. With reducing mobility, this can restrict the residents’ ability to socially interact and engage with their communities. This research investigation analyses the role architecture plays in contributing to this issue and looks at opportunities for improvement through the design of a mixed urban housing development designed to meet the physical and social needs of older persons. Four strategic design tactics were formed during the early design investigations. They directly address the researches aims and objectives through social and spatial means. These tactics are: Tactic 1 - Urban Location, connecting residents to the city, parks and a nearby school; Tactic 2 - Social Circulation is developed to facilitate incidental and planned interactions in the circulation spaces of the developments; Tactic 3 - Mixed Housing provides a range of apartments suited to older persons, students and families; Tactic 4 - Shared Amenities provides health services, leisure activities and a cafe for residents and the wider public to enjoy. The design investigation found that making circulation a primary focus allowed for a stronger relationship between the site and building and allowed for more opportunities for interactions between residents and the public. This research argues that these tactics working together, will provide better outcomes for older persons in health and well being and should be considered as a new and better model of older persons housing.</p>

Age and the City

<p>Social isolation and loneliness affecting a large number of older persons and elderly is a prevalent issue in today’s society. Current older persons and the Baby Boomer generation approaching this age are far more independent than previous generations. Their perception of ‘retirement’ has a negative connotation due to society’s pressures and value placed in remaining independent and useful. The current model of aged care housing, although existing in many forms catered towards different levels of care, is generally seen as a last resort and an acceptance of being dependent on others for day-to-day things. This has led to a trend of ageing in place, in homes which are arguably too big for a single person or couple and often not equipped to adapt to bodily decline. With reducing mobility, this can restrict the residents’ ability to socially interact and engage with their communities. This research investigation analyses the role architecture plays in contributing to this issue and looks at opportunities for improvement through the design of a mixed urban housing development designed to meet the physical and social needs of older persons. Four strategic design tactics were formed during the early design investigations. They directly address the researches aims and objectives through social and spatial means. These tactics are: Tactic 1 - Urban Location, connecting residents to the city, parks and a nearby school; Tactic 2 - Social Circulation is developed to facilitate incidental and planned interactions in the circulation spaces of the developments; Tactic 3 - Mixed Housing provides a range of apartments suited to older persons, students and families; Tactic 4 - Shared Amenities provides health services, leisure activities and a cafe for residents and the wider public to enjoy. The design investigation found that making circulation a primary focus allowed for a stronger relationship between the site and building and allowed for more opportunities for interactions between residents and the public. This research argues that these tactics working together, will provide better outcomes for older persons in health and well being and should be considered as a new and better model of older persons housing.</p>

Cost-effectiveness of upper extremity dry needling in the rehabilitation of patients with stroke

Introduction: Dry needling (DN) has been shown to be effective for the treatment of upper extremity hypertonia in patients with stroke. Purpose: To evaluate the cost-effectiveness of DN in patients with stroke. Methods: A cost-effectiveness analysis was performed in a research study conducted at a Spanish public hospital where patients were classified into two groups with or without DN. Hypertonia was measured using the Modified Modified Ashworth Scale (MMAS), and quality of life (QOL) was assessed using the EuroQoL 5-dimension questionnaire. Data regarding the effects and costs of physiotherapy were presented by calculating the mean and 95% confidence interval. The health outcomes were evaluated considering the rate of responders to the treatment based on the MMAS. Spanish preference weights were used to estimate quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were calculated to determine the economic value of DN. Results: Eighty patients with stroke in the subacute stage of recovery were selected to participate in this study. Based on the rate of responders, the ICER of the DN group was very low. Despite the sensitivity analysis performed, the results of the ICUR were not encouraging. Discussion: Cost-effectiveness with responder rate results were favourable for the DN group and were confirmed by the sensitivity analysis according to levels of care. In addition, our findings revealed that 4 weeks of treatment could be more cost-effective than 8 weeks. DN treatment of the upper extremity appears to be cost-effective based on the rate of responders measured using the MMAS scale.