AKI in Hospitalized Children: Poorly Documented (and Underrecognized)

Background: Acute kidney injury (AKI) is common in hospitalized children. We hypothesized that hospital-acquired AKI would be underrecognized and under-reported, with potential implications for prevention of future AKI and CKD risk stratification.Methods: Five hundred thirty-two cases of AKI occurring over a 1 year period in a tertiary children's hospital in the United States were studied. AKI documentation was defined as any mention of AKI in the admission history and physical note, progress notes, or discharge summary. Nephrology follow-up was defined as a completed outpatient clinic visit within 1 year of discharge. Logistic regression was used to assess factors associated with documentation, consultation, and follow-up.Results: AKI developed during 584/7,640 (7.6%) of hospitalizations: 532 cases met inclusion criteria. Documentation was present in 34% (185/532) of AKI cases and 90 (16.9%) had an inpatient nephrology consult. Among 501 survivors, 89 (17.8%) had AKI in their hospital discharge summary and 54 had outpatient nephrology follow up. Stage 3 AKI, peak creatinine >1 mg/dL and longer length of stay were associated with documentation. Stage 3 AKI and higher baseline creatinine were associated with inpatient nephrology consultation. Inpatient nephrology consultation was positively associated with outpatient nephrology follow up, but documentation in the discharge summary was not.Conclusion: Most cases of AKI were not documented and the proportion of children seen by a nephrologist was low, even among those with more severe injury. Increased severity of AKI was associated with documentation and inpatient consultation. Poor rates of documentation has implications for AKI recognition and appropriate management and follow up.

Routine HIV clinic visit adherence in the African Cohort Study

Background Retention in clinical care is important for people living with HIV (PLWH). Evidence suggests that missed clinic visits are associated with interruptions in antiretroviral therapy (ART), lower CD4 counts, virologic failure, and overlooked coinfections. We identified factors associated with missed routine clinic visits in the African Cohort Study (AFRICOS). Methods In 2013, AFRICOS began enrolling people with and without HIV in Uganda, Kenya, Tanzania, and Nigeria. At enrollment and every 6 months thereafter, sociodemographic questionnaires are administered and clinical outcomes assessed. Missed clinic visits were measured as the self-reported number of clinic visits missed in the past 6 months and dichotomized into none or one or more visits missed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and missed visits. Results Between January 2013 and March 2020, 2937 PLWH were enrolled, of whom 2807 (95.6%) had initiated ART and 2771 had complete data available for analyses. Compared to PLWH 50+, missed clinic visits were more common among those 18–29 years (aOR 2.33, 95% CI 1.65–3.29), 30–39 years (aOR 1.59, 95% CI 1.19–2.13), and 40–49 years (aOR 1.42, 95% CI 1.07–1.89). As compared to PLWH on ART for < 2 years, those on ART for 4+ years were less likely to have missed clinic visits (aOR 0.72, 95% CI 0.55–0.95). Missed clinic visits were associated with alcohol use (aOR 1.34, 95% CI 1.05–1.70), a history of incarceration (aOR 1.42, 95% CI 1.07–1.88), depression (aOR 1.47, 95% CI 1.13–1.91), and viral non-suppression (aOR 2.50, 95% CI 2.00–3.12). As compared to PLWH who did not miss any ART in the past month, missed clinic visits were more common among those who missed 1–2 days (aOR 2.09, 95% CI 1.65–2.64) and 3+ days of ART (aOR 7.06, 95% CI 5.43–9.19). Conclusions Inconsistent clinic attendance is associated with worsened HIV-related outcomes. Strategies to improve visit adherence are especially needed for young PLWH and those with depression.

Engagement with Diabetes Retinal Screening: An analysis of secondary data from the Pacific Eye Institute in Suva

Objectives: Diabetic retinopathy (DR) is one of the primary causes of preventable vision loss and blindness. Diabetic retinopathy screening (DRS) is essential to detect microvascular damage to the retina; it can be performed in primary care or specialist eye health clinics. The system of referral, screening, and treatment relies on an organized primary care referral pathway, accessible services, and at least a basic level of health literacy among those living with or under threat of developing Diabetes Mellitus (DM). Methods: Routinely collected patient data from the Pacific Eye Institute (PEI) in Fiji was analyzed to describe a) clinical and demographic DR patient characteristics and b) characteristics of patients demonstrating higher clinic engagement (using multiple logistic regression). Results: Of 9287 patients who first attended the PEI for DRS between 2012 and 2017, 22% presented with sight-threatening diabetic retinopathy (STDR) in at least one eye. The average duration of DM was 3 years; self-reported glycaemic control was poor. Indo-Fijian or other ethnicity (both vs iTaukei, OR=2.30, 95%CI 1.96-2.70 and OR=2.18, 95% CI 1.63-2.92, respectively; p<0.001), high blood sugar (OR 1.39, 95%CI 1.10-1.75, p=0.006), longer duration of disease (OR=1.21, 95%CI 1.02-1.43, p=0.027), peripheral neuropathy (OR=1.43, 95%CI 1.24-1.65, p<0.001) and STDR (OR=3.30, 95%CI 2.78-3.92, p<0.001) were associated with greater odds of higher clinic engagement. Male gender (Odds Ratio (OR)=0.83, 95% Confidence Interval (CI) 0.72-0.95, p=0.006), younger or older age (both vs 40-70 years; <40 years, OR=0.48, 95%CI 0.37-0.63, ?70 years OR=0.61, 95%CI 0.48-0.76, p<0.001), year of first clinic visit (2013 vs 2012 OR=0.58, 95%CI 0.50-0.69, p<0.001; 2014 vs 2012 OR=0.36, 95%CI 0.30-0.43, p<0.001) and moderate visual impairment (OR=0.67 95%CI 0.56-0.80, p<0.001) were associated with lower odds of high clinic engagement. Conclusion: Our results identify patient groups that may be more vulnerable to lower engagement with eye health services. Increasing engagement may help reduce delays in screening and treatment. Given the projected continued rise in DM in the Pacific region, investing in robust electronic data systems that collect and connect public health and clinical data is imperative. Health literacy is important for the prevention of DM, timely DM diagnosis, and screening for complications such as DR.

The household economic cost of caregivers: children with congenital heart diseases attending to Pediatric Hospital, Sri Lanka

Introduction Congenital heart disease is the commonest type of birth defect of which the estimated prevalence is around 8–12/1,000 worldwide. Caregivers of children with congenital heart diseases are easy victims of high economic burdens and economic instability. Objective The aim was to describe the household economic cost for a clinic visit, of primary caregivers having children with CHDs who are awaiting cardiac surgery attending a cardiology clinic at a major pediatric hospital in Sri Lanka. Methodology A descriptive cross-sectional study was conducted over three months among 427 samples of caregivers of children with congenital heart diseases at Cardiology clinic, Lady-Ridgeway Hospital Sri Lanka. A consecutive convenient sampling method was used to recruit the participant and economic cost was developed based on previous studies, surveys and opinions of an expert in economics. Results Out of caregivers, 75% were unemployed, and the median income was ₹30,000. The median direct cost per clinic visit was ₹1,800. A large proportion of direct cost was showed in traveling expenses. The median indirect cost was ₹1,000. Of the caregivers, 28.7% were falling into catastrophic expenditure during that particular month of the clinic visit. The mean waiting time per clinic visit was 53 minutes. Statistically significant association found distance with transport cost (Chi-square value = 25.14, df = 1, p & .001, OR = 3.4 (CI: 2.1–5.5). There was no statistically significant association between the income of the caregiver and expenditure (Chi-square value = 0, df = 1, p = .998, OR = 1 (CI: 0.678–1.473). Conclusions Assessment of economic burden and its associated factors is vital to recognize high-risk caregivers early, and improvement of monetary support methods.

Healing From a Distance: A Cross-sectional Study on the Diagnostic Reliability of Store-and-Forward Teledermatology (Preprint)

UNSTRUCTURED Telemedicine delivers health care services between two distant locations through the use of information and communication technology. Several medical specializations, such as dermatology, have incorporated telemedicine into their practice. Since dermatologists are trained to diagnose skin, hair, and nail conditions with a clinical eye, teledermatology may be an alternative when a traditional face-to-face clinic visit is not feasible. The purpose of this study was to evaluate the diagnostic reliability of teledermatology. A cross-sectional study was conducted among patients from 2 government hospitals. A total of 39 patients were seen in a face-to-face setting and diagnosed by a consultant dermatologist. A written history of their present illness and accompanying photographs were taken and were shown to 3 consultant teledermatologists, who then diagnosed their condition. Two senior dermatology residents then rated the face-to-face and teledermatology diagnoses as either complete agreement, partial agreement, or no agreement. Descriptive statistics was used to summarize the general and clinical characteristics of the participants. The Cohen kappa was used to assess agreement in the evaluations between the teledermatology and face-to-face diagnoses by senior resident raters #1 and #2. Over 70% of the diagnoses were deemed as either partial or in complete agreement with the face-to-face diagnosis for senior resident rater #1. Similarly, over 80% of the diagnoses were deemed as either partial or in complete agreement with the face-to-face diagnosis for senior resident rater #2. The agreement between the ratings of senior residents #1 and #2 ranged from fair to substantial. The findings of the study showed that the diagnostic concordance of in-person clinicians and teledermatologists ranges from fair to substantial, with over 70% of the diagnoses in partial or complete agreement. Although face-to-face consultations remain the gold standard, teledermatology is an important alternative where dermatologic care is not accessible.

Healing From a Distance: A Cross-sectional Study on the Diagnostic Reliability of Store-and-Forward Teledermatology (Preprint)

BACKGROUND Telemedicine delivers health care services between two distant locations through the use of information and communication technology. Several medical specializations, such as dermatology, have incorporated telemedicine into their practice. Since dermatologists are trained to diagnose skin, hair, and nail conditions with a clinical eye, teledermatology may be an alternative when a traditional face-to-face clinic visit is not feasible. OBJECTIVE The purpose of this study was to evaluate the diagnostic reliability of teledermatology. METHODS A cross-sectional study was conducted among patients from 2 government hospitals. A total of 39 patients were seen in a face-to-face setting and diagnosed by a consultant dermatologist. A written history of their present illness and accompanying photographs were taken and were shown to 3 consultant teledermatologists, who then diagnosed their condition. Two senior dermatology residents then rated the face-to-face and teledermatology diagnoses as either complete agreement, partial agreement, or no agreement. Descriptive statistics was used to summarize the general and clinical characteristics of the participants. The Cohen kappa was used to assess agreement in the evaluations between the teledermatology and face-to-face diagnoses by senior resident raters #1 and #2. RESULTS Over 70% of the diagnoses were deemed as either partial or in complete agreement with the face-to-face diagnosis for senior resident rater #1. Similarly, over 80% of the diagnoses were deemed as either partial or in complete agreement with the face-to-face diagnosis for senior resident rater #2. The agreement between the ratings of senior residents #1 and #2 ranged from fair to substantial. CONCLUSIONS The findings of the study showed that the diagnostic concordance of in-person clinicians and teledermatologists ranges from fair to substantial, with over 70% of the diagnoses in partial or complete agreement. Although face-to-face consultations remain the gold standard, teledermatology is an important alternative where dermatologic care is not accessible.

Factors associated with undertriage in patients classified by the need to visit a hospital by telephone triage: a retrospective cohort study

Background Prehospital telephone triage stratifies patients into five categories, “need immediate hospital visit by ambulance,” “need to visit a hospital within 1 hour,” “need to visit a hospital within 6 hours,” “need to visit a hospital within 24 hours,” and “do not need a hospital visit” in Japan. However, studies on whether present and past histories cause undertriage are limited in patients triaged as need an early hospital visit. We investigated factors associated with undertriage by comparing patient assessed to be appropriately triaged with those assessed undertriaged. Methods We included all patients classified by telephone triage as need to visit a hospital within 1 h and 6 h who used a single after-hours house call (AHHC) medical service in Tokyo, Japan, between November 1, 2019, and November 31, 2020. After home consultation, AHHC doctors classified patients as grade 1 (treatable with over-the-counter medications), 2 (requires hospital or clinic visit), or 3 (requires ambulance transportation). Patients classified as grade 2 and 3 were defined as appropriately triaged and undertriaged, respectively. Results We identified 10,742 eligible patients triaged as need to visit a hospital within 1 h and 6 h, including 10,479 (97.6%) appropriately triaged and 263 (2.4%) undertriaged patients. Multivariable logistic regression analyses revealed patients aged 16–64, 65–74, and ≥ 75 years (adjusted odds ratio [OR], 2.40 [95% confidence interval {CI} 1.71–3.36], 8.57 [95% CI 4.83–15.2], and 14.9 [95% CI 9.65–23.0], respectively; reference patients aged < 15 years); those with diabetes mellitus (2.31 [95% CI 1.25–4.26]); those with dementia (2.32 [95% CI 1.05–5.10]); and those with a history of cerebral infarction (1.98 [95% CI 1.01–3.87]) as more likely to be undertriaged. Conclusions We found that older adults and patients with diabetes mellitus, dementia, or a history of cerebral infarction were at risk of undertriage in patients triaged as need to visit a hospital within 1 h and 6 h, but further studies are needed to validate these findings.

A novel transition clinic structure for adolescent and young adult patients with childhood onset rheumatic disease improves transition outcomes

Background The transition of health care from Pediatric to Adult providers for adolescents and young adults with chronic disease is associated with poor outcomes. Despite the importance of this transition, over 80% of these patients do not receive the services necessary to transition to Adult health care. In 2018, we initiated a transition clinic structure, integrating an Internal Medicine - Pediatrics trained Adult Rheumatologist in a Pediatric Rheumatology clinic to guide this transition. Our goal was to improve transition outcomes. We report the methods of this clinic and its preliminary outcomes. Methods For patients referred to the transition clinic, the Adult Rheumatologist assumed medical management and implemented a six-part modular transition curriculum. This curriculum included a Transition Policy, Transition Readiness Assessment, medication review and education, diagnosis review and education, and counseling on differences between Pediatric and Adult-oriented care. Eligible patients and their families were enrolled in a prospective observational outcomes research registry. Initial data from this transition clinic is reported including adherence with certain aspects of the transition curriculum and clinic utilization. Results The transition clinic Adult Rheumatologist saw 177 patients in 2 years, and 57 patients were eligible for, approached, and successfully enrolled in the registry. From this registry, all patients reviewed the Transition Policy with the Adult Rheumatologist and 45 (78.9%) completed at least one Transition Readiness Assessment. Of the 22 patients for whom transition was indicated, all were successfully transitioned to an Adult Rheumatologist. 17 (77.3%) continued care post-transition with the transition clinic Adult Rheumatologist, and 5 (22.7%) continued care post-transition with a different Adult Rheumatologist. The median time between the last transition clinic visit and first Adult clinic visit was 5.1 months. Conclusions Our experience demonstrated the success of our clinic model regarding participation in the transition curriculum and improved clinic utilization data. Our results are an improvement over transition rates reported elsewhere that did not implement our model. We believe that this structure could be applied to other primary care and subspecialty clinics. Trial registration This research was approved by the University of Utah Institutional Review Board (IRB) in January 2019 (IRB_00115964). Patients were retrospectively registered if involved prior to this date.

Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study

Background Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults. Methods The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk. Results Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use. Conclusions Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.