DiversityNursing Blog

Written by Markus MacGill

www.medicalnewstoday.com 

3D printing has come to the rescue of severe cases of a childhood disease in which the windpipe is softened, leading to collapse of the airway and breathing failure. Previously lacking any adequate intervention, tracheobronchomalacia has found an innovative fix in three babies whose condition presented them with little chance of reaching young childhood.

Researchers at the University of Michigan's C.S. Mott Children's Hospital in Ann Arbor say the three boys have become the "first in the world to benefit from groundbreaking 3D-printed devices" to stent their airways in such a way as to allow the supports to keep up with their growth.

A follow-up of all three patients published in the journal Science Translational Medicine shows the personalized bioresorbable splint implants have worked with "promising results."

Pediatric tracheobronchomalacia (TBM) sees excessive collapse of the airways during breathing that can lead to life-threatening cardiopulmonary arrests (halted heart and breathing).

The cartilage supporting the airway can strengthen as children with the condition grow, the study paper goes on to explain, but severe cases of the disease require aggressive treatment - and those children are at "imminent risk of death."

Before this new approach to provide an early treatment option for TBM, the only conventional therapies available also carried life-threatening complications of their own.

Babies needed tracheostomy tube placement with mechanical ventilation, requiring prolonged hospitalization, and complications often led to cardiac and respiratory arrest. For example, the rate of respiratory arrest owing to tube occlusion runs as high as 43% of pediatric tracheostomy procedures a year.

Survivors: Kaiba, Ian and Garrett

But none of the newly developed 3D-printed devices have caused any complications for the three children treated, including Kaiba, who at 3 months old was the first to receive the new technology, 3 years ago. The stents were also inserted into 5-month-old Ian and 16-month-old Garrett.

Designed to accommodate airway growth while preventing external compression over a period of time before bioresorption, the technology allows for the particular problem of radial expansion of the airway over the critical period of growth. "If a child can be supported through the first 24 to 36 months of tracheobronchomalacia, airway growth generally results in a natural resolution of this disease," write the authors.

Senior author Dr. Glenn Green, associate professor of pediatric otolaryngology at C.S. Mott, says: "Before this procedure, babies with severe tracheobronchomalacia had little chance of surviving. Today, our first patient Kaiba is an active, healthy 3-year-old in preschool with a bright future." Dr. Green adds:

"The device worked better than we could have ever imagined. We have been able to successfully replicate this procedure and have been watching patients closely to see whether the device is doing what it was intended to do.

We found that this treatment continues to prove to be a promising option for children facing this life-threatening condition that has no cure."

Dr. Green describes in the video below how he and his colleagues at the University of Michigan worked on finding the solution.

Dr. Green strives enthusiastically for the lives of babies born with the condition, which he says in a post on the hospital's Hail to the little victors blog is often misdiagnosed as treatment-resistant asthma. He adds that it is a rare congenital condition affecting about 1 in 2,200 births, and the severe cases are even rarer, with most children growing out of the milder cases by 2 or 3 years of age.

"Kaiba's parents, April and Bryan, were left watching helplessly each time he stopped breathing, praying that something would change and doctors' predictions that he would never leave the hospital again weren't true," writes Dr. Green in 2013.

The 3D-printed splints were computational image-based designed to be customizable so that the following parameters could be made bespoke to the individual patient's anatomy on "the submillimeter scale:"

• Inner diameter, length and wall thickness of the device
• Number and spacing of suture holes.

Not being a closed cylinder, the design of the tubes gave an opening to allow placement but also expansion of the radius as the airways grew. All the inserts placed around the airways were made of polycaprolactone, a polymer that harmlessly dissolves in the body at a rate to allow the technology time to support the growing cartilage.

For Garrett's bespoke device on his left bronchus, the opening had a spiral shape to it, to allow a device to be fitted concurrently around, and grow with, his right bronchus, too.

Freedom from intensive care treatments

The Michigan team also share findings showing that the success of the devices meant the young children were able to come off of ventilators and no longer needed paralytic, narcotic and sedating drugs.

There were improvements in multiple organ systems and problems that had prevented the babies from absorbing food, so now they could be free of intravenous therapy.

The research doctors had received urgent approval from the US Food and Drug Administration to do the procedures, but it is early days for the strategy to become routine for babies with TBM. The case report published today was not designed to test the safety of the devices - so it may yet be possible that rare complications are found to result from treatment in some cases. Dr. Green says:

"The potential of 3D-printed medical devices to improve outcomes for patients is clear, but we need more data to implement this procedure in medical practice."

The specialist surgeon performing the operations, Dr. Richard Ohye, head of pediatric cardiovascular surgery at C.S. Mott, believes the cases provide the groundwork for a potential clinical trial in children with less-severe forms of TBM.

By Jacque Wilson and Deborah Brunswick

www.cnn.com 

It was just another day with another massive allergic reaction. 

She can always tell when one is coming on. "I just get this overwhelming sense of -- they call it impending doom." Her labradoodle, Moose, starts alerting, licking her hands frantically.

"I'll feel like I'm being stabbed in the stomach, and then it gets hard to breathe and my throat and tongue start swelling. And we have to treat it really fast." 

On that particular day in March, multiple EpiPens didn't slow the reaction. The paramedics who arrived to take Brynn to Greenville Memorial Hospital, or "Hotel Greenville" as she likes to call it, knew her well. When she asked for her security blanket, they knew to hand her her smartphone.

"New day, new crisis," Brynn quips as she tells the story, as if it's about her first day of college or a shopping trip gone wrong. It might as well be. When you're allergic to life, a near-death experience is no big deal. 

Center of attention

Less than a week after her trip to the hospital, Brynn, 21, is back at home in Easley, South Carolina. She lies on her back, her head near the foot of her bed, chattering away as her mom changes the access to her chest port. 

Melissa Duncan, a paralegal by day, dons a mask and surgical gloves before disinfecting the area around the tube that's connected to Brynn's jugular vein. The disinfectant burns, and Brynn's blood pressure hits 150/102. Her heart rate rockets to 128. 

"The meds we have to give her to keep her alive, she reacts to," Melissa says, shaking her head. "Never in a million years did I think I would be doing this. "

Brynn was seemingly a normal kid -- until she wasn't. Yes, she was a fussy baby. Yes, she got sick often as a child, Melissa muses out loud -- but what kid doesn't? Brynn was also incredibly energetic, always the center of attention. Her father, Barry, jokingly rues the day she learned to talk. She started taekwondo at the age of 9 and had her black belt by the time she was 11. That was the same year doctors diagnosed Brynn with IBS, or irritable bowel syndrome. 

"She's always been --" Melissa Duncan pauses. 

"High maintenance!" Brynn fills in with a laugh. 

It wasn't until shortly before her 16th birthday in 2010 that Brynn had her first serious allergic reaction. The next two years became a blur of sick days and doctors' appointments.

Brynn saw specialist after specialist. The gastrointestinologist diagnosed her with gastroparesis, or partial paralysis of the stomach muscles. A cardiologist said she had POTS, or Postural Orthostatic Tachycardia Syndrome -- meaning that when she stood up for longer than a few minutes, her blood pressure dropped, leaving her light-headed and nauseated. A Wake Forest doctor diagnosed her with Ehlers-Danlos syndrome, a connective tissue disorder that causes fragile skin and overly flexible joints. 

After doing hours of research, Melissa, Barry and Brynn came up with their own diagnosis: mast cell disease. They found a specialist online, Dr. Lawrence Afrin, who at the time was working in Charleston. They waited nearly nine months to see him, but hearing him confirm their suspicions was life-changing.

Mast cells are the regulators of your immune system. They're the ones that release histamine when a bug bites, or when you come into contact with an allergen. They basically sound the alarm that lets the rest of your immune system know something is wrong.

Until recently, the only mast cell disease doctors had identified was mastocytosis, which is characterized by "abnormal proliferation and activation" of the body's mast cells -- meaning there are way too many and they act in strange ways. 

But in the last few years doctors such as Afrin have started to recognize that there are many different layers to mast cell disease. For instance, Brynn has mast cell activation syndrome, meaning her mast cells act strangely, but they're not growing in number. 

"It's like I'm living in a 24/7 allergic reaction," Brynn explains simply. 

Fruit, vegetables, milk, soy, nuts, smoke, perfume, the sun -- you name it, Brynn is allergic to it. But it's not really about the specifics; the allergens change depending on how "angry" her mast cells are that day, she says. On good days, she can eat small amounts of plain meat or mashed potatoes. On bad days, even using her feeding tube causes her extreme pain. 

Not everyone with mast cell activation syndrome has it as bad as Brynn does. "Oh God, no," Afrin says when asked. "No, no, no, no." 

But mast cells are located in your connective tissue, including your skin and the lining of your stomach and intestine. They can affect every system in the body, Afrin says, so the disease is capable of causing all the symptoms Brynn experiences.

You have to ask yourself, he says: "Is this poor patient so uniquely unlucky to have acquired so many different, independent problems? Or is it more likely that there is just one thing going on?"

Of course, having a diagnosis didn't make living with mast cell disease any easier. 

In 2012, Brynn was admitted to the hospital 30 times. She started having seizures and episodes of dystonia -- painful, violent muscle contractions that are "scary to see and scary to experience." On multiple occasions, doctors have had to put casts on her legs to prevent her joints from bending in the wrong direction.

"I've seen doctors and nurses step back, kind of like 'What is this?'" Barry Duncan says. 

Every time she went to the ER, Brynn was given a large dose of steroids to calm the inflammation. She's now steroid dependent -- and likely will be for life. 

"We could be here for days, and you still would not understand all the inner workings of Brynn and all of her medical issues," Melissa Duncan says. "But I think the underlying one is the mast cell disease, which is a beast, and continues to become a bigger beast, day by day."

 Living in a bubble

Brynn spent her 19th birthday in the hospital. An allergic reaction made her miss a zip lining trip for her 20th. On December 31, her 21st birthday, when many young adults would be out celebrating the legal drinking age with friends, she was at home still recuperating from Christmas. She had joined the holiday festivities by eating a special pizza -- made with fake bread and fake cheese. 

"It's nasty," Barry Duncan says with a laugh. "It's the worst pizza you've ever tasted." But "for her, the worst pizza you've ever had ... tastes really good."

Brynn dreams about real stuffed crust pizza sometimes. And mozzarella sticks. Occasionally she lets her spunky attitude drop, and you see that she understands the effect her illness has on those around her. 

Her parents have spent weeks sleeping in cramped hospital chairs. Her younger siblings have missed vacations and school ceremonies; they've learned how to inject Brynn with an EpiPen, and how to hold her limbs still during a dystonia episode. 

"There's a lot of guilt that goes along with having a chronic illness," Brynn says. "You feel like a burden. And people can tell you you're not, but no matter what, in your head, you feel that you are."

She has moments when she gets jealous of her high school friends who are doing all the things she can't -- attending college, moving out, finding boyfriends. She and her new friends, others with chronic illnesses she met online, have a saying: "Single and ready to mingle -- as long as you have good health insurance."

And with a giggle, the dark moment passes. Skyping with her friends keeps her spirits up. She's prolific on Instagram, with more than 5,300 followers, and writes regularly on her blog, which is called "Brynn's Bubble." 

"A lot of people with this disease ... do, in a sense, have to live in a bubble, because it's really difficult to get the symptoms under control," Brynn says. "You spend a lot of time alone. And it can be very isolating. But thanks to social media, I haven't felt alone."

Over the last two years, Brynn and her family have made progress in managing her disease. She was one of the first patients in the nation to be put on a continuous IV of antihistamine. Intravenous immune globulin, or IVIG, therapy, when a healthy donor's plasma is used to boost a patient's immune system, cut in half the number of drugs she needs. 

Of course, she still needs a lot -- a compounding pharmacy delivers a box to her house once or twice a week. The meds make her brain foggy. She punctuates conversations with "Where'd that thought go?" But that doesn't stop her from talking. She plans to keep talking until mast cell disease receives the attention she feels it deserves. 

"'You don't look sick' -- that's one of the comments that I get a lot. Or they say, 'At least it's not cancer,' and that's another hard one, because these illnesses can be just as devastating," Brynn says. "The difference is they're not understood. And the only way to change that is to somehow bring awareness to it."

Early in her taekwondo career, Brynn's instructor told her that she could win a match before it even began -- just by staring down the opponent. She plans to fight mast cell disease the same way.

Alexandra Wilson Pecci

www.healthleadersmedia.com 

Hospitals have a broader responsibility to elderly trauma patients than just the time spent within their walls, and should consider updating their strategies to ensure the best outcomes for these patients, research suggests.

Elderly trauma patients are increasingly likely to be discharged to skilled nursing facilities, rather than inpatient rehabilitation facilities (IRF), finds a study in The Journal of Trauma and Acute Care Surgery published in the April issue.

Discharge to skilled nursing facilities for trauma patients has, however, been associated with higher mortality compared with discharge to inpatient rehabilitation facilities or home.

Researchers wanted to "better characterize trends in trauma discharges and compare them with a population that is equally dependent on post-discharge rehabilitation." They not only examined trauma discharges, but also discharges of stroke patients, who have been taking up more inpatient rehabilitation facility beds.

Using data from 2003–2009 data from the National Trauma Data Bank and National Inpatient Sample, the retrospective cohort study found that elderly trauma patients were 34% more likely to be discharged to a skilled nursing facility and 36% less likely to be discharged to an inpatient rehabilitation facility. By comparison, stroke patients were 78% more likely to be discharged to an inpatient rehabilitation facility.

This is despite the findings of a 2011  JAMA study of patients in Washington State showing that "Discharge to a skilled nursing facility at any age following trauma admission was associated with a higher risk of subsequent mortality."

The Journal of Trauma and Acute Care Surgery study notes that "elderly trauma patients are the fastest-growing trauma population," which leads to the question: Where should hospitals be investing their money and time to ensure the best outcomes for these patients?

"I think hospitals should be investing in post-acute care discharge planning," says Patricia Ayoung-Chee, MD, MPH, Assistant Professor, Surgery, NYU School of Medicine, and lead author of the study. "What's the best post-acute care facility for patients? And it may end up needing to be individualized."

She says reimbursement and insurance factors have "played more of a role than anybody sort of thought about" in discharges, rather than what is always necessarily best for patients.

For example, to be classified for payment under Medicare's IRF prospective payment system, at least 60% of all cases at inpatient rehab facilities must have at least one of 13 conditions that CMS has determined typically require intensive rehabilitation therapy, such as stroke and hip fracture.

"I think the unintended consequence is that we may be discharging patients to the best post-acute care setting, but we also may not be," Ayoung-Chee said by email, and that question "is only now being looked at in-depth."

She says hospitals should think about truly appropriate discharge planning upfront.

Proactive Hospitals
For instance, at admission, hospitals can find out who the patient lives with, or what their social support system is like. If they have a broken dominant hand after a fall, will they be able to get help with their groceries? Do they live alone? Will they be able to use the bathroom?

Caring for patients also doesn't end when patients leave the hospital, she adds. Hence the study's title: "Beyond the Hospital Doors: Improving Long-term Outcomes for Elderly Trauma Patients."

Ayoung-Chee says the next step in her research is to look at a more longitudinal picture, following individual patients to see what factors play into their function or lack of function.

But hospitals can do some of that work on a smaller scale, with internal audits to determine which facilities have the best post-acute care outcomes. For instance, they could spend time examining which facilities had fewer readmissions compared to others, as well as how long it took patients to get home and their how satisfied they were with their care.

Other research is also trying to determine which facilities are best for elderly trauma patients. For instance, a second study, also published in The Journal of Trauma and Acute Care Surgery, shows that geriatric trauma patients have improved outcomes when they are treated at centers that manage a higher proportion of older patients.

One of the overarching takeaways from Ayoung-Chee's research is the idea that hospitals have a broader responsibility to patients than just the time spent within their walls.

"What we do doesn't just end upon patient discharge. If we truly want to get the biggest bang from our buck, we're going to have to think about the entire continuum," she says.

That could range from working to prevent falls that can cause elderly trauma, to seeing patients through all of the appropriate care needed to expect a good functional outcome. Good healthcare for elderly trauma patients should extend beyond the parameters of morbidity and mortality, and toward returning patients to their original functional status and, ultimately, independence, says Ayoung-Chee.

"Our long-lasting effect as healthcare providers isn't just what we do in the hospital," she says. "And we have to start thinking outside."

www.medgadget.com 

Medication errors continue to plague the clinical community and even rare cases of mistakes can make a big splash in the news. And for a good reason: we all expect to be treated than harmed when receiving medical care. A new device is currently in the third round of pilot testing, including at major retail pharmacies and Purdue University, that may help avoid prescription errors altogether. The IdentRx system from PerceptiMed, a Mountain View, California firm, optically analyzes every single pill that will be given to a patient to make sure it precisely matches each prescription.

It is the only device that visually inspects each pill, recognizing the manufacturer imprints on them all. The system confirms that the pills themselves, and not only the container bottles, match the issued prescriptions, hopefully preventing errors just before the pills are handed to the patients.

http://myfox8.com

 If you ever needed any evidence that nurses care vastly about every single patient they encounter, this is it.

A video posted last week on Facebook shows a nurse reacting as one of her patients stands up for the first time in 11 days.

The story as, posted by Texas mom Becky Miller:

“Our daughter, Bailey, had complete paralysis from the waist down for 11 days with no explanation as to why. This video is one of her favorite nurses coming onto her shift and not knowing that Bailey had started walking this day.”

The nurse immediately bursts into tears upon seeing Bailey, screaming, “Thank you, Lord.”

Miller said Bailey had no feeling or movement in her legs the day before. Doctors did not know what caused Bailey to lose feeling in her legs.

Commenters on Reddit immediately took the opportunity to commend nurses, and all of the work and long hours they put in daily.

“Nurses are great people,” one commenter wrote. “You’d have to be humanitarian to be a nurse.”

By SYDNEY LUPKIN

abcnews.go.com

The Easter Bunny has some sweet competition in the form of two therapy rabbits at NYU Langone Medical Center in Manhattan.

Nutmeg and Clovis, both 5 years old, live on the 13th floor of the hospital, and this week, they visited patients for Bunny Day, the hospital's nondenominational springtime celebration. They wore rabbit ears (yes, really), a bonnet, and sat on a basket of eggs.

"The bunny cart is decorated to the hilt, and then we'll go and see patients and work with patients," said Gwenn Fried, manager of horticultural therapy services at NYU Langone. "The patients adore it."

As she travels the hospital with one rabbit at a time (Rabbits need breaks, too!), she said she hands patients a plastic Easter egg, and it contains either a sticker or a bunny treat.

"The bunny is very excited about the bunny treat," she laughed.

The bunnies visited 15 patients on Thursday and will visit more today and tomorrow, Fried said.

The rabbits are part of a therapy program that's been at the hospital for about 13 years. Sometimes, doctors recommend the bunny therapy, and sometimes patients request it, but Fried said she's seen them work magic on children and adults alike.

"One dad just said, 'I really think Clovis changed our lives,'" Fried told ABC News last year. "He's the most patient animal I've ever seen in my life."

Shefali Luthra

Source: www.cnn.com

You know the one. It might as well have been stitched together with paper towels and duct tape, and it usually leaves the wearer's behind hanging out.

"You're at the hospital because something's wrong with you -- you're vulnerable -- then you get to wear the most vulnerable garment ever invented to make the whole experience that much worse," said Ted Streuli, who lives in Edmond, Okla., and has had to wear hospital gowns on multiple occasions.

Put another way: "They are horrible. They are demeaning. They are belittling. They are disempowering," said Camilla McRory of Olney, Md.

Hospital gowns have gotten a face-lift after some help from fashion designers like these from Patient Style and the Henry Ford Innovation Institute.

The gowns are among the most vexing parts of being in the hospital. But if efforts by some health systems are an indicator, the design may be on its way out of style.

The Cleveland Clinic was an early trendsetter. In 2010, it introduced new gowns after being prompted by the CEO, who often heard patient complaints when he was a practicing heart surgeon. That feedback led to a search for something new, said Adrienne Boissy, chief experience officer at the hospital system.

The prominent academic medical center ultimately sought the help of fashion icon Diane von Furstenberg, settling on a reversible gown with a front and back V-neck, complete derriere coverage, and features such as pockets, softer fabric and a new bolder print pattern.

Patients "loved the gowns," Boissy said. "People felt much more comfortable in the new design, not just physically but emotionally." In recent years, she added, "hospitals are looking at everything they do and trying to evaluate whether or not it contributes to enhancing the patient experience." 

It's all part of a trend among hospitals to improve the patient reviews and their own bottom lines -- fueled in part by the health law's focus on quality of care and other federal initiatives. The Centers for Medicare & Medicaid Services increasingly factors patients' satisfaction into its quality measures, which are linked to the size of Medicare payments hospitals get.

Sometimes the efforts involve large capital improvement projects. But they can also mean making waiting rooms more comfortable, improving the quality of food served to patients or, as in this case, updating hospital gowns.

Ultimately, this focus leads to "a better patient experience," said John Combes, senior vice president of the American Hospital Association.

The Detroit-based Henry Ford Health System is in the process of updating its gowns, an initiative that began when the system's innovation institute challenged students at the city's College for Creative Studies to identify and offer a solution to one hospital problem.

The students responded with the suggestion to redo the garment that has often been described by patients as flimsy, humiliating, indecent and itchy. The process took three years, but last fall, the institute unveiled a new and improved version. It's made of warmer fabric -- a cotton blend -- that wraps around a patient's body like a robe and comes in navy and light blue, the hospital's signature colors.

Patient expectations are part of the calculus. They "are demanding more privacy and more dignity," said Michael Forbes, a product designer at the Henry Ford Innovation Institute.

When the institute tested his gown design, Forbes said, patient-satisfaction scores noticeably increased in a few days.

The new gown "was emblematic...of an attitude that was conveyed to me at the hospital -- that they cared about me as a whole human being, not just the part they were operating on," said Dale Milford, who received a liver transplant during the time the redesign was being tested. "That was the subtext of that whole thing, was that they were caring about me as a person and what it meant for me to be comfortable."

But replacing the traditional design is no easy task. What patients wear needs to be comfortable yet allow health professionals proper access during exams, meaning it must open and close easily. The gowns also need to be easily mass-manufactured, as well as efficiently laundered and reused.

New designs, though, can be expensive. After Valley Hospital of Ridgewood, N.J., switched to pajamas and gowns that provide extra coverage, costs went up $70,000 per year, said Leonard Guglielmo, the facility's chief supply chain officer, because the new garments cost more to buy and maintain.

Beyond cost, more ingrained cultural expectations might also play a role in what hospitals think patients should wear, said Todd Lee, an assistant professor of medicine at McGill University, who co-authored a 2014 study in the journal JAMA Internal Medicine, examining whether gowns were important and whether patients might be fine wearing their own or hospital-provided pants, instead of or along with gowns.

Often, doctors reported that pants or undergarments beneath gowns would have been okay, but patients said they were never given those options. Traditional gowns make it easier to examine patients quickly, and several doctors Lee spoke to seemed shocked at the idea that patients might wear garments other than the open-backed gown during their stay.

But the most common challenge isn't necessarily doctor expectations or costs. It's navigating hospital bureaucracies, said Dusty Eber, president of the California-based company PatientStyle, which designs and sells alternative gowns. In his company's experience, hospital decisions are often made by committees, not individuals.

A Dutch organization called "Ambulance Wens" (Ambulance Wish) fulfills the last wishes of terminally ill patients free of charge thanks to its 200 medical volunteers.

The company says, "There are still too many patients who die without getting to close everything. One of those reasons is the inability to achieve certain desires because the patient is no longer mobile and other existing facilities are inadequate for this purpose."

Special ambulances and stretchers help transport the patients safely and comfortably. Typical excursions include a visit to the beach, a visit to a neighbor who is also no longer mobile, and various places where the patient has special memories.

This woman's final wish was to visit the Rijksmuseum in Amsterdam.

Another woman enjoys the view from her favorite vacation destination in Tuscany.

This gentleman asked for one last view from the Euromast observation tower.

And this man asked to see the mills in Kinderdijk one last time.

Amsterdam is not the only place doing such wonderful things. A hospice outside Seattle made an old forest ranger's dying wish come true.

"Ed expressed one last hope to the hospice chaplain: He wanted to commune with nature one more time."

As the hospice wrote on its Facebook page, "People sometimes think that working in hospice care is depressing. This story ... demonstrates the depths of the rewards that caring for the dying can bring."

Source: www.sunnyskyz.com

Jonathan Winston Jones

The disconcerting news was the doctor had to Google the issue first to figure out the best medical advice.

"My provider just did a Web search to figure out what dose of hormones I should be on, and put me on the highest dose," Sallans said. That could have been a dangerous choice. "Starting too high of a dose too quickly can cause a lot of health problems, particularly to cardiovascular health."

Fortunately, Sallans didn't have any health complications.

But his experience left him with a mission. He volunteers to speak with medical institutions, as well as with businesses and colleges, to urge them to be more LGBT inclusive. 

While a growing number of medical schools are teaching future doctors how to address health concerns that can be specific to the lesbian, gay, bisexual and transgender communities, studies show current doctors only get about five hours of training, if they get any at all.

For members of the LGBT community who live in more rural and conservative areas like Nebraska, the struggle to get good, or at least up-to-date, medical care may be even more difficult. 

In general, legal protections and institutional supports for LGBT Nebraskans are already thin, spotty or nonexistent.

On March 2, the United States District Court struck down Nebraska's ban on marriage for same-sex couples, but that ruling is on appeal. 

Without the legal institution of marriage, LGBT Nebraskans typically lack family health benefits, unless their employers provide them to same-sex partners.

A 2014 study from the Williams Institute at the University of California Los Angeles found that states without LGBT legal protections in place see lower rates of health insurance coverage for LGBT residents than states with protections.

That plays out in Nebraska. 

A 2014 study from researchers at the University of Nebraska Omaha found that LGBT residents in the rural parts of the state have lower rates of health insurance coverage than their counterparts in urban areas. 

Even when LGBT Nebraskans have health insurance, they struggle to find providers versed in lesbian, gay, bisexual and transgender heath care needs. 

Research shows that LGBT individuals often experience health issues linked to being regular targets of discrimination or social stigma. Discrimination has been linked to higher rates of substance abuse, suicide and stress-related illnesses, which can include heart problems, obesity, eating disorders and cancer. 

If the available doctors are not familiar with the increased rates of these issues, they may provide inadequate care.

Patients who find their doctors do not understand their issues may also delay treatment, often with bad health outcomes, said Jay Irwin, an assistant professor of sociology at the University of Nebraska-Omaha and a researcher in LGBT health. 

Sometimes patients are turned away by providers who don't want to treat LGBT patients, particularly if there are no laws to prohibit such discrimination. 

Irwin has completed studies that focus on the health care challenges of lesbians in rural areas and found that many people feel isolated and are afraid to come out -- or risk discrimination in the medical office.

Nebraska's sheer size doesn't help. Sixteenth largest in the nation by geography, members of its LGBT community often live far from large cities with significant LGBT populations and with teaching hospitals with staff members who have experience working with members of that community.

The Human Rights Campaign's 2014 Healthcare Equality Index named four Nebraska health care facilities, all in Omaha, as leaders in LGBT health care equality. 

Omaha is on the state's eastern border with Iowa. LGBT residents in western Nebraska -- for instance, places like North Platte -- have to travel 270 miles in either direction, to Omaha or Denver, Colorado, to reach facilities designated as leaders by the Human Rights Campaign. 

People who work within the health care system have seen some improvement when it comes to treating members of the LGBT community. 

Jill Young is the client services manager at Nebraska AIDS Project's Scottsbluff, Nebraska, office in the western part of the state.

She recalled when she started working there in the late 1990s she saw medical staff refuse care to LGBT people with HIV/AIDS. 

"We had nurses, for example, who said they wouldn't serve patients with HIV/AIDS," Young said. "But we've come a long way since then." 

Young has seen more hospitals in the region adopting policies that are supportive of LGBT residents, including one that just started recognizing same-sex partners' wills as legal documents that will allow them access to their partners when they are being cared for in areas restricted to immediate family only.

But she said she still sees too many LGBT residents traveling great distances to get care and she still sees too many patients who don't seek medical care until it is too late. 

"We still go to the hospital," she said, "and see people who are days away from dying."

Eric Yarwood, 44, has more experience than he would like with Nebraska's health care facilities. 

He spent over 100 days last year at hospitals in Omaha for complications related to germ cell cancer.

He had nine rounds of chemotherapy, three stem cell transplants, his third surgery two weeks ago and five more days for followup last week. 

For all but four of the days he was in the hospital, his partner, Aaron Persen, 36, was at his side every evening. "Aaron and I are a unit," Yarwood said. "I can count on my fingers the number of times he didn't come." 

While the couple has found the overwhelming majority of physicians and medical staff to be "genuinely supportive" of their relationship, there still were a few instances when they felt uncomfortable and unaccepted, once with a physician and another time with a nurse. 

"I'm not sure how often the medical staff works with gay couples or receives training on how to work with gay couples," Yarwood said. 

Yarwood's prognosis is good, and the couple looks with optimism to a future of having more access to LGBT-inclusive health care facilities and a more inclusive state overall. 

"Hopefully, by the time we get through the cancer and save a little money," Persen said, "Nebraska will follow most other states and allow our relationship to be legally recognized."

Source: www.cnn.com

Liberia released its last Ebola patient, a 58-year old English teacher, from a treatment center in the capital Thursday, beginning its countdown to being Ebola-free.

"I am one of the happiest human beings today on earth because it was not easy going through this situation and coming out alive," Beatrice Yardolo said after her release.

She says she became infected while caring for a sick child.

"I was bathing her. I used to carry her from the bathroom alone because nobody wanted to take any risk. That is how I got in contact," she said.

Yardolo, a mother of five, said she had been admitted to the Chinese-run Ebola treatment center in Monrovia on Feb. 18.

"I am so overwhelmed because my family has been through a very difficult period from January to now. And to know that it's all coming to an end is a very delightful news. I'm so happy," Yardolo's son, Joel Yardolo, told reporters.

Tolbert Nyenswah, assistant health minister and head of the country's Ebola response, says there are no other confirmed cases of Ebola.

"For the past 13 days the entire Republic of Liberia has gone without a confirmed Ebola virus disease," Nyenswah told reporters. "This doesn't mean that Ebola is all over in Liberia."

After a 42-day countdown - two full incubation periods for the virus to cause an infection - the country can be declared Ebola-free. Officials are monitoring 102 people who have been in recent contact with an Ebola patient.

Since the epidemic started a year ago, Liberia has recorded 9,265 cases of Ebola, with 4,057 deaths. But the World Health Organization says there are almost certainly more cases than that. WHO says close to 24,000 cases have been recorded, and close to 10,000 deaths, in the entire West African epidemic.

-- The Associated Press and Reuters contributed to this story

Source: www.nbcnews.com