Supportive Care Team Challenges on The Border In the Pandemic

Background: Hospice and Palliative Medicine (HPM) is a subspecialty of medicine, recognized in 2008 by the ABMS, with over 200 fellowship programs nationally. This Supportive Care Team (SCT) interprofessional paradigm of MD’s, NP’s, PA’s, MSW’s, Pharm.D.’s, chaplains, RN’s and therapists holistically cares for persons with advanced life-limiting illnesses. UTRGV SOM and DHR Health, in extreme south Texas on the border with Mexico, inaugurated the HPM fellowship in 2019. Its current fellow began in 2021. The intent of the fellowship was for care and services to flow uninterruptedly throughout the RGV. However, in early 2020 the world changed indelibly due to the COVID-19 pandemic. Methods: In early 2020, plans were to inaugurate the DHR Health Inpatient Palliative Care Unit (iPCU). In fact, the building’s façade says, “DHR Hospice.” (see photo) However, nearly on its opening day, DHR Health required its use as their first COVID Care Unit, which it has continued until the present time. This QI Project utilized deidentified chart reviews. Results: Approximately 9 / 107 SCT patients at the DHR main hospital became enrolled into the General Inpatient Care (GIP) category. This data is compared to national rates (https://www.nahc.org/wp-content/uploads/2017/10/GIPAAHPM.pdf). Discussion: The SCT quickly pivoted to develop a “mobile PCU (mPCU)” which continued to reside within the main DHR Health hospital, rendering end-of-life and pain crisis interprofessional care to persons near life’s end. The team became these patients’ “home away from home” at DHR. Conclusion: While it was not the intent of the SCT for this venue (the main hospital) to be its primary site for hospice care, it has continued to do so in the continued face of adversity and challenge as the pandemic has now gone through its second and third waves

The CTSA University of Texas Health Science Center (UTHSC) Northeast—Tyler and Rio Grande Valley Success Story: How Rural, Underserved Academic Communities Rapidly Built a Robust Engine for Collaborative COVID-19 Clinical Research

In 2018, The University of Texas Health Science Center– Tyler and University of Texas Rio Grande Valley were invited to develop clinical research units for an existing Clinical and Translational Science Award (CTSA) consortium with the objective to equip medically underserved, economically disadvantaged communities and subsequently to deploy COVID-19 clinical trials in response to a public health emergency

Efficacy and Safety of COVID-19 Convalescent Plasma in Hospitalized Patients: A Randomized Clinical Trial

Importance: There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19. Objective: To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen. Design, setting, and participants: CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation. Interventions: A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline). Main outcomes and measures: The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8. Results: Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR Conclusions and relevance: In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use. Trial registration: ClinicalTrials.gov Identifier: NCT04364737

Post-Surgical Emergency After-Hours Calls: Prevalence, Concerns, and Management

Objective The purpose of this study was to investigate the prevalence, nature, and management of post-surgical emergency after-hours calls in a dental school setting with predoctoral students, graduate students/residents, and faculty providers. Methods A patient chart review (March 2018–February 2020) for post-surgical calls through the emergency after-hours pager system was conducted at the Marquette University School of Dentistry. The total number of surgical procedures, procedure type, the timing of call, operator experience, concern, and recommendation given during the call were documented. Results During the review period, 83 calls (from 75 patients) were recorded after 8,487 surgical procedures (1% of procedures). Patients called 5.4 ± 0.8 days postoperatively. Procedure type affected call prevalence (p = 0.04), with most calls made after extractions (69.9% of all calls; 1% of extractions; 58/5,725), implant placement (6%; 0.9% of implant placements; 5/530) and periodontal plastic surgery (6%; 3.1% of all plastic surgeries; 5/161). The most common concern was pain (72.3%), then swelling (36.1%), bleeding (12%), and infection (9.6%). Operator experience did not affect call prevalence. Recommendations given were next business day follow-up (79.5%), reinforcement of already given postoperative instructions (51.8%), prescription (15.7%), and hospital emergency department (ED) visit (7.2%). Conclusions Post-surgical emergency after-hours calls in a dental school setting occur within the first postoperative week and are rare, unrelated to operator experience, typically prompted by pain, and rarely resulting in referral to hospital ED. The use of a pager system is adequate for the management of after-hours emergencies and may reduce self-referrals to the hospital ED

Dementia, Delirium, and Depression

Changes in mental status can affect many residents during their stay in a post-acute or long-term care (PA/LTC) facility. Changes in cognition can either be acute as in seen in delirium, subacute as seen in depression, or chronic as seen in dementia. As such assessment by the practitioner can be challenging as one or more of these conditions may occur in the same resident. Understanding the similarities and dissimilarities between the clinical features of dementia, delirium, and depression is paramount when evaluating the resident who presents with a change in mental status. The chapter will emphasize how to differentiate between these three conditions and to describe the common presentations of dementia, delirium, and depression, and review their differential diagnosis and treatment. Screening tools are discussed as well as the pharmacologic, non-pharmacologic and behavioral interventions in the treatment of delirium, depression, and dementia

Patient-reported Outcomes Following Guided Bone Regeneration: Correlation with Clinical Parameters

Objectives Postoperative oral health-related quality of life is procedure-dependent and may vary during early healing. There is scarce evidence on patient-reported outcome measures (PROMs) after extraction and guided bone regeneration (GBR) or on the clinical parameters influencing PROMs. This prospective observational study aimed to evaluate PROMs during the first 2 weeks following extraction and GBR and correlate them with clinical parameters. Methods Patients undergoing extraction and GBR (bone graft and resorbable membrane) at a single tooth-bound site were recruited. PROMs (pain, swelling, difficulty of mouth opening, and OHIP-14) were recorded immediately preoperatively, and at 2, 7, and 14 days postoperatively. Flap advancement, gingival and mucosal thickness, duration of surgery, and wound opening were the clinical parameters assessed. Results Twenty-seven patients were included. All PROMs peaked on postoperative day 2, decreased subsequently and were significantly correlated with each other. Although 41–56% of patients reported moderate to severe pain, swelling, or mouth opening difficulty on day 2, most patients experienced mild or no symptoms throughout the postoperative period. Pain, swelling and difficulty of mouth opening were determinants of OHIP-14 and were correlated with all OHIP-14 domains during different time points. Wound opening peaked on day 7. Flap advancement, soft tissue thickness, wound opening, duration of surgery and preoperative PROMs affected postoperative PROMs. Conclusions Within the limitations of the present study, postoperative symptoms after guided bone regeneration are worst on day 2 and oral health-related quality of life is significantly impacted by pain, swelling, difficulty of mouth opening, surgery duration and flap advancement. Clinical Significance This is the first study to report PROMs following extraction and GBR with particulate bone graft and resorbable membrane in preparation for implant placement. It will help guide both practitioners and patients on what should be the anticipated experiences following such a routinely performed surgery

Guided Bone Regeneration-Associated Tissue Swelling: A Digital Three-Dimensional Assessment

Statement of problem Postoperative swelling following guided bone regeneration (GBR) may affect the dimensions of interim restorations and/or delivery timing. However, quantitative assessment of post-GBR swelling or its evaluation for possible impact on regenerative outcomes is lacking. Purpose The purpose of this prospective clinical study was to quantify post-GBR swelling and correlate it with clinical parameters and outcomes. Material and methods Participants (n=25) undergoing standardized extraction and GBR protocol were recruited. Site-specific swelling was measured as ridge width, height, and volume changes based on intraoral scans recorded preoperatively, immediately postoperatively (IP), and at 2 days, 7 days, 14 days, and 4 months. The parameters and outcomes assessed were gingival and mucosal thickness, flap advancement, surgery duration, wound opening, and bone gain. The Friedman 2-way analysis of variance by ranks was performed, and the Spearman correlation coefficients (ρ) were computed (α=.05). Results Ridge width and height peaked at 2 days (2.1 mm for both from IP; P\u3e.999 and P=.888, respectively). At 4 months, both decreased significantly compared with IP (−4.2 mm and −1.9 mm respectively, P=.043), mucosal thickness (ρ=0.51, P=.021), and flap advancement (ρ=0.58, P=.008). Conclusions Following GBR, site-specific swelling peaked on postoperative day 2 and subsided by day 7 (width) or 14 (height). Soft tissue thickness and flap advancement affected post-GBR bone width. Months after guided bone regeneration (GBR) with particulate bone allograft and resorbable membrane, horizontal bone gain has been reported to reach approximately 3.5 mm. Dimensional change can be seen immediately after surgery because of the added bone graft material. However, during early healing, GBR sites exhibit additional dimensional changes attributable to soft tissue swelling. Swelling, a common cardinal inflammation sign, may be exacerbated by more traumatic interventions2. Compared with simple flap elevation, GBR surgery leads to increased swelling because of the vertical and periosteal releasing incisions for flap advancement and tension-free closure, introduction of biomaterials, and increased surgery duration. Significant swelling may increase the probability of wound dehiscence or membrane exposure, a complication associated with decreased post-GBR bone gain. Although post-GBR swelling has been documented as a patient-reported outcome, its clinical quantification and its potential relationship with specific clinical parameters (surgery duration, flap advancement, soft tissue thickness) or with surgical outcomes (wound opening, bone gain) is unknown. Therefore, the primary purpose of this clinical study was to quantify post-GBR swelling (ridge height and width changes). Its secondary purpose was to correlate post-GBR swelling with surgery- and site-specific clinical parameters (duration of surgery, soft tissue thickness, flap advancement) and relevant outcomes (wound opening, bone gain). The null hypothesis was that no significant changes in ridge dimensions from IP would be found at the postoperative follow-up

Identifying Solutions to Ambulatory Faculty Recruitment, Retention, and Remuneration in Graduate Medical Education: An AAIM Position Paper

Perspectives Viewpoints •Graduate medical education (GME) directors should target their efforts on faculty development and salary support/payment for teaching as highly valued incentives for ambulatory resident teaching.•GME programs from Title VII and Teaching Health Centers are potential solutions for ambulatory faculty recruitment and retention at both university-based and community-based institutions.•Because faculty produce income from their clinical and teaching efforts with residents, an educational relative value unit structure provides an equitable method to reward GME teaching faculty