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Tackling No-Show Rates: Addressing Barriers in a Free Clinic's Attendance
No full textProblem Statement:
Health disparities persist due to social determinants of health impacting appointment no-show rates at the Matthew 25 clinic.
Rationale:
Addressing health disparities has been at the forefront of challenges faced in the medical field. Social determinants of health (SDOH) have a significant impact on patient populations, often contributing to health disparities (1). SDOH refers to environmental factors that contribute to one’s overall health and longevity (2,3). It is estimated that SDOH account for 50% of the variation in health outcomes. Intervening on factors that contribute to poor SDOH could have a profound impact on many lives. Matthew 25, a free clinic in Fort Wayne, IN, serves a large immigrant population and natives who are of a low socioeconomic status. While the clinic helps to bridge the gap in healthcare by providing free healthcare services, it is hypothesized that SDOH are influencing the quality of care the clinic can provide. This study’s objective is to evaluate the effectiveness of the proposed survey model on increasing healthcare accessibility by observing its effects on rate of missed appointments.
Methods:
This was a single-center prospective questionnaire-based research project designed to determine the reasons for missed appointments and what resources can assist in reducing the no-show rate. This study was approved by the Indiana University Institutional Review Board. Participants included patients scheduled for appointments from November 2023 to the end of December 2023. Inclusion criteria were patients aged 18 and above who had at least one scheduled appointment during the study period. Any patient under the age of 18 years, who communicates exclusively in any language other than English or Spanish, or has substantial cognitive impairment was excluded. The data was stored on a Microsoft Excel Spreadsheet. The ultimate objective of this project was to implement interventions that would mitigate the no-show rate at Matthew 25.
The survey was administered by clinic staff, including volunteers and nurses, at the conclusion of each patient's visit prior to discharge. A verbal explanation of the intention of the study was given to potential participants before they completed the questionnaire. To encourage participation, the questionnaire was designed to be anonymous. The instrument comprised of ten questions. Completed surveys were securely stored at the clinic in a designated folder until the data was digitized, after which the physical questionnaires were disposed of securely.
Results:
A total of 64 participants completed the survey, shedding light on the primary reasons for missing appointments at Matthew 25. The most common reason was work obligations (19 participants, 29.7%), followed by simply forgetting (17 participants, 26.6%). Lack of transportation affected 10 participants (15.6%), while 5 participants (7.8%) cited lack of childcare. Seven respondents (10.9%) identified the absence of a translator as a significant barrier, and 4 (6.3%) selected "Other" reasons. A smaller percentage (3.1%) reported fear or anxiety about attending the clinic.
A second survey, with 149 responses, assessed preferred reminder times. Results showed 14% preferred reminders 1 day prior, 38% preferred 2 days prior, 43% opted for 1 week before, and 5% wanted a reminder 1 month in advance.
No-show rates did not significantly change within the first three months after posting informational materials, possibly due to insufficient time for patients to schedule follow-up visits. A newer Spanish-language poster was recently added, but its effects are still being evaluated.
These findings emphasize the importance of addressing social determinants of health on a community level, such as employment conflicts, transportation, and language barriers, to reduce no-show rates and improve healthcare access. Additionally, increasing patient awareness through multilingual outreach efforts, like the newly introduced Spanish-language poster, may further enhance attendance rates over time.
Potential Impact:
The survey highlighted common barriers that prevented patients from attending their appointments, allowing us to create English and Spanish posters with information about free services to help patients become more aware of the resources that, ideally, would make it simpler to attend appointments.
References:
1. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl:S28-S40. doi:10.1177/0022146510383498
2. Chang CD. Social Determinants of Health and Health Disparities Among Immigrants and their Children. Curr Probl Pediatr Adolesc Health Care. 2019;49(1):23-30. doi:10.1016/j.cppeds.2018.11.009
3. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood). 2002;21(2):60-76. doi:10.1377/hlthaff.21.2.6
Laser fenestration and shape memory polymer embolization of type II endoleaks
No full textIntroduction: Treatment is recommended for type II endoleaks (T2ELs) with abdominal aortic aneurysm (AAA) sac expansion, but durable endovascular treatment remains challenging. Shape memory polymer (SMP) embolization plugs are a self-expanding, bioabsorbable polyurethane polymer designed to fill space rapidly within a vessel and provide a scaffold for rapid thrombosis. This case series describes a single institution's experience with transendograft laser fenestration and SMP embolization to treat difficult T2ELs.
Methods: This is retrospective review of seven patients who underwent transendograft laser fenestration and SMP embolization. Laser fenestration was performed to target the endoleak. SMP plugs were then deployed into the aortic sac, and the endograft was realigned. The primary outcome was persistent aneurysmal sac growth at 1- and 6-month follow-up.
Results: This study included five patients with prior infrarenal aneurysm repairs, one with a juxtarenal aneurysm repair, and one with a thoracoabdominal aneurysm repair. Five patients had previously undergone iliolumbar artery coiling, with a median of 1.0 prior interventions (interquartile range [IQR], 0.5-2.0) across the cohort. The median AAA diameter at the time of SMP embolization was 75.0 mm (IQR, 68.5-78.0 mm), with a median growth of 20.0 mm (IQR, 6.5-23.0 mm) from the index endovascular aortic repair. After embolization, three patients experienced continued AAA growth leading to additional reinterventions, including one patient who underwent endograft explant. Two patients showed growth at 6 months requiring reintervention. This resulted in an overall 6-month freedom from AAA growth of 42.9% in the entire cohort.
Conclusions: The present series yielded a 6-month freedom from AAA growth in approximately 43% of patients. Refractory T2ELs represent a complex subset of patients with aneurysmal disease and, with future procedural refinements, SMP embolization holds promise as a minimally invasive therapy for this disease process
Every voice has its bright and dark sides: Understanding observers' reactions to coworkers' voice behaviours
No full textThe majority of research on voice has focused on how employee voice influences voicers and targets of voice (e.g. supervisors and organizations). We advance theory on voice by examining how third-party observers react to expressions of voice behavior by coworkers. Drawing from affective events theory (AET), we examine the potential benefits and detriments of coworker voice behaviours. Results from an experience sampling study and an experiment revealed that coworker voice was associated with an increase in third-party observers' inspiration, prompting third-party observers to engage in their own voice behaviours. Although coworker voice did not have a significant main effect on third-party observers' distress, this relation was moderated by third-party observers' zero-sum beliefs. Specifically, daily coworker voice behaviour was more positively related to third-party observers' distress when third-party observers' zero-sum beliefs were higher (vs. lower). Third-party observers' distress, in turn, was associated with an increase in interpersonal deviance behaviours. Overall, our theorizing and model answer why, when and for whom the bright versus dark side of coworker voice is likely to occur for third-party observers
Type 1 diabetes presenting in adults: Trends, diagnostic challenges and unique features
No full textType 1 diabetes (T1D) has been historically regarded as a childhood-onset disease; however, recent epidemiological data indicate that adult-onset T1D accounts for a substantial proportion of cases worldwide. There is evidence that adult-onset T1D is associated with the classic T1D triad of elevated genetic risk, the presence of islet-specific autoantibodies and progression to severe insulin deficiency. In this article, we review our understanding of the commonalities and differences between childhood and adult-onset T1D, and we highlight significant knowledge gaps in our understanding of the diagnosis, incidence, trajectory and treatment of adult-onset T1D. Compared to children, adults presenting with T1D exhibit differences in genetic risk, immunologic profiles and metabolic outcomes, including differences in the type and number of autoantibodies present, genetic associations and total genetic burden, rates of C-peptide decline, the persistence of C-peptide in long-duration disease and glycaemic control. In addition, obesity and metabolic syndrome are increasingly common in adults, which not only blurs the clinical distinction of adult-onset T1D from type 2 diabetes (T2D) but also likely contributes to differences in metabolic outcomes and rates of progression. Because T2D is so prevalent in the adult population, adult-onset T1D is misclassified as T2D in at least one in three cases, leading to delays in appropriate treatment. Current diagnostic tools, including autoantibody testing and C-peptide measurement, are underutilised or lack specificity in distinguishing adult-onset T1D from atypical T2D. Additionally, the impact of different responses to disease-modifying therapy between adults and children is unclear. Addressing these knowledge gaps requires expanded epidemiological studies, diverse patient registries and refined classification criteria to improve early detection and treatment strategies. A deeper understanding of adult-onset T1D will be critical to reduce the burden of misdiagnosis, lead to earlier diagnosis and treatment and optimise population-based screening approaches in this under-recognised population. PLAIN LANGUAGE SUMMARY: Type 1 diabetes (T1D) is an autoimmune disease that causes metabolic and nutritional complications due to the destruction of insulin-producing pancreatic β cells. T1D was formerly known as "juvenile diabetes" because it was assumed that most cases occurred in childhood; however, recent epidemiological data show that nearly half of all T1D cases are diagnosed in adulthood. Despite the high prevalence of adult-onset T1D, there are challenges with correctly diagnosing T1D in adulthood, and significant knowledge gaps remain regarding the incidence, trajectory, and treatment of adult-onset T1D. In this article, we summarize the current understanding of commonalities and differences between childhood and adult-onset T1D. Particularly, we highlight age-related differences in genetic risk, immunologic profiles, and metabolic outcomes and complications. Finally, we highlight key gaps in our understanding of adult-onset T1D that need to be addressed to reduce the burden of misdiagnosis and allow for better screening and treatment of T1D in adulthood
Diagnostic challenges in culture-negative infective endocarditis: a case of histoplasma endocarditis: a case report
No full textIntroduction: Histoplasma capsulatum is a fungal infection primarily associated with respiratory diseases and conditions that compromise the immune system. Cardiac involvement is extremely rare and presents a significant diagnostic challenge, mainly owing to often inconclusive results from blood cultures, histopathology, and serological tests. This case not only highlights a rare causative organism but also examines an atypical presentation of endocarditis linked to Histoplasma capsulatum. It underscores the importance of thoroughly evaluating the patient's medical history and underlying conditions, particularly when clinical presentations and laboratory results are unusual or unclear.
Case presentation: A 34-year-old Hispanic male with end-stage renal disease on peritoneal dialysis owing to Immunoglobulin A nephropathy presented with atypical positional chest pain not related to physical activity. His recent medical history included pulmonary histoplasmosis. Initially, he was treated for suspected pericarditis; however, treatment was unsuccessful. Further examination and diagnostic testing revealed endocardial vegetations. The patient's presentation did not exhibit the classical clinical signs and laboratory findings typically associated with infective endocarditis. An extensive infectious workup, including serologic and microbiologic testing, failed to identify a definitive pathogen. A comprehensive review of the patient's medical history, which included recent pulmonary histoplasmosis, inconsistent compliance with antifungal therapy, and immune dysfunction related to his end-stage renal disease, was essential for guiding clinical decision-making. The patient was ultimately managed successfully with appropriate antifungal therapy and underwent surgical valve replacement.
Conclusion: This case highlights the complexity of diagnosing infective endocarditis when it presents atypically and is associated with rare causative organisms, such as Histoplasma capsulatum. Lacking the classical clinical features, laboratory findings, and common predisposing risk factors. It highlights the importance of a comprehensive evaluation of the patient's clinical history and overall condition to guide accurate diagnosis and effective management
Prenatal opioid exposure alters pain perception and increases long-term health risks in infants with neonatal opioid withdrawal syndrome
No full textBackground: Opioids are often prescribed for pain relief, yet they pose risks such as addiction, dependence, and overdose. Pregnant women have unique vulnerabilities to opioids and infants born to opioid-exposed mothers could develop neonatal opioid withdrawal syndrome (NOWS). The study of opioid-induced epigenetic changes in chronic pain is in its early stages. This study aimed to identify epigenetic changes in genes associated with chronic pain resulting from maternal opioid exposure during pregnancy.
Methods: We analyzed DNA methylation of chronic pain-related genes in 96 placental tissues using Illumina Infinium Methylation EPIC BeadChips. These samples comprised 32 from mothers with infants prenatally exposed to opioids who needed pharmacologic NOWS management (+Opioids/+NOWS), 32 from mothers with prenatally opioid-exposed infants not needing NOWS pharmacologic treatment (+Opioids/-NOWS), and 32 from unexposed control subjects (-Opioids/-NOWS).
Results: The study identified significant methylation changes at 111 CpG sites in pain-related genes among opioid-exposed infants, with 54 CpGs hypomethylated and 57 hypermethylated. These genes play a crucial role in various biological processes, including telomere length regulation (NOS3, ESR1, ESR2, MAPK3); inflammation (TNF, MAPK3, IL1B, IL23R); glucose metabolism (EIF2AK3, CACNA1H, NOTCH3, GJA1); ion channel function (CACNA1C, CACNA1H, CLIC4, KCNQ5); autophagy (CTSS, ULK1, ULK4, ATG5); oxidative stress (NGF, NRG1, OPRM1, ATP1A2); aging (GRIA1, NGFR, PRLR, EIF4E); cytokine activity (TRPV4, RUNX1, CXCL8, IL18R1); and the risk of suicide (ADORA2A, ANKK1, GABRG2, IGSF9B). These epigenetic changes may influence 48 signaling pathways-including cAMP, MAPK, GnRH secretion, estrogen signaling, morphine addiction, circadian rhythms, and insulin secretion-profoundly affecting pain and inflammation-related processes.
Conclusion: The identified methylation alterations may shed light on pain, neurodevelopmental changes, and other biological mechanisms in opioid-exposed infants and mothers with OUD, offering insights into NOWS and maternal-infant health. These findings may also pave the way for targeted interventions and improved pain management, highlighting the potential for integrated care strategies to address the interconnected health of mothers and infants
Improving Confidence in Performing Clinical Procedures Through Peer-Driven Training Sessions for Preclinical Medical Students
No full textIntroduction: Preclinical medical students self-report low levels of confidence in performing procedural skills, most often when performing procedures during clinical rotations. Early clinical exposure (ECE) during rotations can increase student confidence in their performance, but resource limitations hinder opportunities for preclinical medical students. A student-led procedure training session (SLPTS) can effectively provide clinical procedure exposure to preclinical medical students outside of the formal medical curriculum, which could increase student confidence prior to the start of clinical rotations.
Methods: We used Kern's six-step curriculum development approach to create an SLPTS, which included presession videos, procedure background, peer demonstrations, and hands-on practice in suturing technique, abscess incision and drainage, endotracheal intubation, and peripheral vein access. Confidence levels were measured before and after the session using a scale of 1-10 (1 = low confidence, 10 = high confidence). Mean changes in confidence (ΔC) were analyzed with a paired t test. We conducted focus groups and analyzed common themes using an inductive coding process.
Results: Among 35 student learners (first year, n = 17; second year, n = 18; survey respondents, n = 31), significant increases in confidence were observed for basic suturing (ΔC = 5.16), abscess incision and drainage (ΔC = 5.39), endotracheal intubation (ΔC = 4.55), and peripheral vein access (ΔC = 5.74; p < .001 for all).
Discussion: The SLPTS effectively provided ECE and increased student confidence in performing clinical procedures outside of the formal curriculum. Collaboration between students and faculty could further integrate such training into the official curriculum
Framework for Kidney Health Follow‐Up Among Neonates With Critical Cardiac Disease: A Report From the Neonatal Kidney Health Consensus Workshop
No full textAcute kidney injury is common among neonates with critical cardiac disease. Risk factors and associations with kidney-related outcomes are heterogeneous and distinct from other neonates. As survival of children with critical cardiac disease increases to adulthood, the burden of chronic kidney disease is increasing. Thirty percent to 50% of adults with congenital heart disease have impaired kidney function, even in the absence of prior kidney injury episodes. This may be related to the current standardized acute kidney injury criteria, which may not fully capture clinically meaningful kidney injury and long-term kidney health risks. An improved understanding of which neonates with critical cardiac disease should undergo kidney health follow-up is imperative. During the National Institutes of Health-supported Neonatal Kidney Health Consensus Workshop to Address Kidney Health meeting conducted in February 2024, a panel of 51 neonatal nephrology experts focused on at-risk groups: (1) preterm infants, (2) critically ill infants with acute kidney injury, and (3) infants with critical cardiac disease. The critical cardiac disease subgroup, comprising multidisciplinary experts, used a modified Delphi process to achieve consensus on recommendations for kidney health follow-up. In this report, we review available data on kidney health follow-up in critical cardiac disease and summarize the 2 consensus-based recommendations. We introduce novel diagnostic and risk-stratification tools for acute kidney injury diagnosis in neonates with cardiac disease to guide follow-up recommendations. Finally, we identify important knowledge gaps, representing areas of focus for future research. These should be prioritized to understand and improve long-term kidney health in critical cardiac disease
eIF4E assembly into C. elegans germ granules is essential for its repressive function
No full textMetazoan germ cells form intracellular germ granules, cytoplasmic RNA-protein condensates that contain a variety of RNAs and proteins essential for germline identity, maintenance, and fertility. P granules are a type of C. elegans germ granule proposed to be sites of mRNA repression. Proper P granule assembly is dependent on PGL-1 and its granule-forming protein relatives. Numerous RNA-binding proteins localize to P granules, like the eIF4E mRNA cap binding homolog, IFE-1. IFE-1 directly interacts with PGL-1 in vivo and in vitro. The molecular function of P granules remains enigmatic. Here, PGL-1 was molecularly dissected in vivo to determine protein regions required for P granule assembly, binding partner recruitment, and germ cell development. A specific region in the PGL-1 C-terminus was necessary and sufficient for IFE-1 recruitment to P granules and for fertility. IFE-1 RNA targets were identified, and reporters of top gene targets were repressed in the adult germline. This repression was dependent on PGL-1 and its IFE-1 binding peptide. These findings provide evidence that IFE-1 and P granules are a factor and site of mRNA repression, respectively. This repression required IFE-1 assembly into P granules, supporting the model that RNA-protein condensate assembly is necessary for its biological and biochemical functions