Conectar
by Zvika Orr, Levi Jackson, Evan Avraham Alpert, Mark D. Fleming
The emergency department (ED) often serves as the first point of care for those with mental health conditions. Mental health-related visits to the ED tend to increase during and after public health crises. In Israel, the war that started in 2023 has had substantial adverse effects on the population’s mental health, increasing the need for emergency services for people with mental health conditions. This article examines the perceptions and experiences of Israeli staff providing care to patients with mental health conditions in an ED of a tertiary-care hospital in Jerusalem. Based on an inductive thematic analysis of 24 semi-structured interviews with staff members, this study sheds new light on the staff’s challenges in treating these patients. The study found that providers navigated a high level of stigma towards people with mental illness. Many providers were aware that negative perceptions of these patients were potentially harmful and may lead to diagnostic overshadowing, and in some cases, they tried to mitigate the effects of stigma. Staff often viewed patients with mental illness as inappropriate users of the ED, assuming limited responsibility for these patients. The findings also illuminate the providers’ inadequate training and skills for treating and managing mental health, as well as organizational and structural constraints. The article recommends ways to improve the treatment of mental health in EDs, such as educational workshops, more support of mental health specialists in EDs, providing calm environments, working alongside experts by experience, and conducting person-centered risk assessments. EDs should strengthen collaboration and referral pathways to community-based mental health services. Moreover, the healthcare system must provide patients with alternative sources of care, such as community crisis centers. These steps can mitigate the expected post-war mental health crisis in Israeli EDs and are relevant to many other countries.Each year, millions of people experience recurrent diverticulitis episodes. Elective sigmoid colon resection reduces the risk of recurrence, but The American Society of Colon and Rectal Surgeons recommends individualising surgical decisions based on the impact of the condition on a patient’s quality of life (QoL). However, no threshold for QoL impairment has been established to guide decision-making, and evidence comparing elective colectomy with medical management in terms of QoL limitation is limited. To address these gaps and to guide treatment decision-making, we designed the Comparison of Surgery and Medicine on the Impact of Diverticulitis (COSMID) trial.
The COSMID trial is a large, pragmatic randomised trial including patients with QoL-limiting diverticulitis that aims to determine if partial colectomy is superior to medical management and explore subgroups that are more likely to respond to each treatment.
COSMID will recruit 250 English-speaking and Spanish-speaking adults with imaging-confirmed and QoL-limiting diverticulitis (defined using a modified diverticulitis-related QoL survey). Participants are randomly assigned to undergo elective partial colectomy or receive comprehensive medical management (eg, selected from options including fibre, probiotics, mesalamine and rifaximin). A total of 100 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary outcome is the time-averaged score of the Gastrointestinal Quality of Life Index at 6, 9 and 12 months after randomisation. Secondary outcomes include clinical adverse events, healthcare utilisation, recurrent episodes of diverticulitis and additional patient-reported outcomes like the Diverticulitis Quality of Life instrument, decisional regret and work productivity. Exploratory analyses aim to identify differential treatment effects based on patients’ characteristics.
This trial was approved by the Vanderbilt Institutional Review Board (IRB) on 26 August 2019 (IRB #191217). Vanderbilt serves as the institutional review board of record for the following study sites: Albany Medical College, Allegheny Health, Atrium Health Carolinas Medical Center, Virginia Mason Medical Center, Boston University Medical Center, Cedars-Sinai Medical Center, UT Health Lyndon B. Johnson Hospital, Medical University of South Carolina, New York-Presbyterian Queens, Stanford University, University of Pennsylvania, University of California San Diego, University of California San Francisco, University of Colorado Denver, University of Florida, University of Iowa, University of Utah, University of Washington Medical Center, University of South Florida, University of Rochester Medical Center, University of Texas Southwestern Medical Center, Virginia Commonwealth University, Lahey Hospital & Medical Center, Weill Cornell Medical Center and Northwell Health. Rush University Medical Center (approved 8 January 2020), Columbia University Medical Center (approved 28 January 2020), Northwestern University (approved 19 March 2020), Mount Carmel Health System (approved 5 May 2020) and Memorial Health University Medical Center (approved 4 April 2022) are regulated and were approved by their respective IRBs. Results from this trial will be presented at international conferences and published in peer-reviewed journals.
Respiratory tract infections (RTIs) cause significant child morbidity and mortality. Periodical influenza vaccination and respiratory syncytial virus (RSV) prophylaxis can reduce this burden in risk groups. However, in the Caribbean, the optimal timing of these interventions is unclear due to a lack of epidemiological data. We aimed to investigate pathogens associated with RTI disease burden and pathogen specific seasonality in the Caribbean in the context of COVID-19 to achieve optimal timing of preventive measures.
We conducted a retrospective study using patient records and pathogen detection data from St. Maarten Medical Center from 1 September 2018 to 1 September 2023. We performed regression to associate pathogens with outcomes and seasonality.
RTI diagnoses accounted for 50.8% (N=7380) of outpatient cases and 28.0% (N=508) of inpatient cases. RSV and rhino/enterovirus were associated with more frequent oxygen requirement (OR 5.1 (95% CI 2.3 to 11) and OR 2.3 (95% CI 1.2 to 4.3), respectively) and tachypnoea/dyspnoea (OR 4.9 (95% CI 2.0 to 13) and OR 2.8 (95% CI 1.6 to 5.2), respectively) than other pathogens post-COVID-19. RSV consistently peaked during June/July and September/October, preceding RSV prophylaxis administration in October.
The overall burden on the healthcare system due to RTI visits and admissions was high. Higher disease severity was associated with RSV and rhino/enterovirus infections; therefore, universal RSV prophylaxis should be considered, and timing should be optimised based on seasonality.
Taking multiple medicines can be appropriate but has the potential to be problematic. The Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence THrough the Years (iSIMPATHY) project used the 7-Steps person-centred approach for medication reviews, supporting patients and clinicians to define and achieve realistic goals for drug treatment, and helping enable patients to lead healthy and active lives.
To assess the impact of pharmacist-led comprehensive person-centred medication reviews using the 7-Steps methodology.
iSIMPATHY sought to transform the approach to optimisation of medicinces through the delivery of person-centred medication reviews for people taking multiple medicines in primary care, hospital and outpatient clinics. The reviews were conducted by embedding a single approach for polypharmacy management, building on key recommendations from SIMPATHY.
Interventions made were graded, with 82% being classified as clinically significant and 4% potentially preventing major organ failure, adverse drug reactions or incidents of similar clinical importance. The average number of medications reduced from 12 to 11, with 92% of the reviews resulting in more appropriate medication use, thereby decreasing the likelihood of medication-related harm. Inappropriate medicines were stopped, reduced or altered to improve appropriateness. There were significant healthcare resource utilisation benefits as indicated by a positive return on investment for both medication and healthcare costs with a quality-adjusted life year gain of 7.4 per 100 patients.
Pharmacist-led, person-centred medication review using the 7-Steps approach was delivered across jurisdictions and healthcare settings, with positive impacts on the number and appropriateness of medicines, clinical interventions and cost savings outweighing expenditure on the service. The approach is scalable by means of the tools and resources developed over the duration of the project.
Type 1 diabetes (T1D) demands self-management skills, knowledge and confidence to prevent medical complications. Adolescents living with T1D have distinct developmental challenges resulting in a worsening in glycaemic stability, irregular care and an increased risk for complications all while transitioning to adult healthcare. Age-specific online platforms could facilitate transition by fostering self-management education and support. The Support online self-guided training platform has been shown to increase the confidence of adults with T1D in managing their glycaemia. We aim to test the effectiveness of Support-t (ie, adapted for youth), compared with usual care, in improving haemoglobin A1c (HbA1c) and to understand the context of its implementation.
We will conduct a multisite, assessor-blinded, randomised controlled, parallel group, two-arm, superiority trial, evaluating effectiveness and implementation of Support-t versus usual care in 200 adolescents (14–16 years old) living with T1D. The active arm will have an 18-month access to Support-t, and their healthcare team will be trained on the platform’s content. The control arm will receive usual care. The primary outcome is HbA1c at 18 months. Secondary outcomes include self-efficacy for diabetes self-management, transition readiness, diabetes-specific quality of life, diabetes distress, continuous glucose monitoring metrics, number of severe hypoglycaemic events, diabetic ketoacidosis, T1D-related emergency department visits and hospitalisations as well as engagement and satisfaction. A subgroup of participants in the active arm and of healthcare providers will be interviewed assessing barriers, facilitators, engagement and fidelity of the intervention. Primary analysis will be by intention-to-treat. The difference in mean HbA1c at 18 months (with a 95% CI) will be calculated between both arms. A cost-effectiveness analysis is also planned.
December 8, 2024 version of the protocol was approved by the McGill University Health Centre Research Ethics Board (MP-37-2024-9734). Results will be disseminated through peer-reviewed publications and patient-partners’ network.
ClinicalTrials.gov (NCT05910840).
‘Hotspotters’ are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. As reliable data on effective interventions for this population are scarce, the goal of this study is to assess the cost-effectiveness of proactive, personalised, integrated care for this group.
The Hotspotters Project is planned as a stepped wedge cluster randomised controlled trial in 20 primary care practices in the Netherlands. All practices and participants will begin with standard care during the control period (2–8 months), followed by an intervention (12 months) consisting of a positive health intake with goal setting, multidisciplinary meetings, a personalised care plan and proactive care management. The study will conclude with a follow-up (2–8 months), resulting in a total study duration of 22 months. We plan to include 200 patients with (a) problems on two or more life domains and (b) at least two acute care encounters in the previous year. Possible Hotspotters are identified using an Adjusted Clinical Groups-based algorithm or via a local primary healthcare team.
Questionnaires and routine care data will be used to gather data on cost-effectiveness, which will then be assessed using multilevel analysis, with levels for the individual, cluster and duration of control period. Secondary outcomes will include psychological outcomes on self-regulation (proactive coping, patient activation, self-efficacy and intention), experience of care (satisfaction, perceived autonomy support and qualitative data from focus groups) and quality of life, qualitative analysis of the Positive Health approach, implementation outcomes and process evaluation including integration of care.
The Ethics Committee of Leiden University Medical Centre granted approval (METC-LDD, P21.123). Results will be shared through peer-reviewed publication and (inter)national conference presentations.
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