Clinic Contact Research Articles

Co-created improvement goals and strategies for implementing SBIRT and MAUDin primary care settings in a facilitator-supported, tailored implementation study.

Evidence-based approaches to screening and treatment for unhealthy alcohol use have the potential to reduce morbidity and mortality but are currently underutilized in primary care settings. To support implementation of screening, brief intervention, and referral to treatment (SBIRT) and medication-assisted treatment for alcohol use disorder (MAUD) by identifying goals co-developed by clinics and practice facilitators in a flexible implementation study. In a pragmatic implementation study, we used practice facilitation to support the implementation of SBIRT and MAUD in 48 clinical practices across Oregon, Washington, and Idaho. Our study used a tailored approach, in which facilitators and clinics co-identified implementation goals based on clinic needs. We used clinic contact logs, individual interviews, group periodic reflections with practice facilitators, and exit interviews with clinic staff to inform qualitative analysis. With support from practice facilitators, clinics identified goals spanning SBIRT, MAUD, reporting, targeted patient outreach, and quality improvement capacity. Goals addressed both the technical (e.g. data tracking) and social (e.g. staff training) aspects of SBIRT and MAUD. A decision tree summarizes emergent findings into a tool to support future implementation of SBIRT in primary care settings. A facilitator-supported, tailored approach to SBIRT implementation enabled clinics to identify a variety of goals to improve SBIRT and MAUD implementation. These identified priorities, along with a decision tree describing the hierarchical structure of these goals, could support future implementation efforts.

Variasjonar i psykisk helsevern – status og forklaringsfaktorar

Introduction: Reducing unwanted variation is one of the goals of Norwegian health policy. We mapped variations among municipalities in Health Region West in the use of specialist health services that fall under the chapter on mental health care and substance use in ICD-10, and looked at various variables that may be related to these. Method: Data were retrieved from the Samhandlingsbarometer, an online open-source portal, and systematized by the authors. The annual rate per 1,000 inhabitants of hospital admissions and outpatient/day treatments per municipality was used as the result variables. Bivariate and multivariable linear regression were useful for investigating the association between independent variables and outcome variables. Results: The results showed large differences in the use of specialist health services in the municipalities, with a factor of 6.7 (hospital admissions) and 8.3 (outpatient clinic contacts). In adjusted analyses, we found that higher overall costs for health and care services in the municipalities were associated with fewer hospital admissions (β –.378 – 95% CI –.616; –.142) and fewer outpatient/day treatments (β –.541 –.649; –.323). The number of users in municipal mental health services was associated with more hospital admissions (β .514 .298; .726) and more use of psychotropic drugs in connection with outpatient/day treatments (β .485 .263; .703). Home-based care for younger inhabitants (< 67 years) was also positively associated with the use of both hospital admissions (β .494, .266; .724) and outpatient/day treatments (β .471 .239; .703). Both the prevalence of marginalisation (not in employment, education or training) and a high level of education were associated with higher use of outpatient clinics (β .355 .132; .577 and β .296 .064; .528), while a dispersed housing pattern was associated with fewer hospital admissions (β –.421 –.679; –.158) and outpatient day treatments (β –.386 –.627; –.145). The explained variance of the multivariable models was small to moderately high (R2 .07 – .51). Conclusion: Morbidity, use of resources for municipal health care, and sociodemographic differences are related to the rate of admissions and outpatient/day treatments. The findings do not unequivocally indicate that greater resource use in the municipalities covaries with less use of specialist health services, although some of the findings point in that direction. Relative inequalities in municipalities, where many inhabitants have a high level of education and where many experience marginalisation (not in employment, education or training) are associated with high consumption of specialist health services in mental health care. Keywords: practice variation, specialist health service, psychiatry, substance use treatment

Effectiveness of a novel digital patient education programme to support self-management of early rheumatoid arthritis: a randomized controlled trial.

To evaluate the effectiveness of a novel digital patient education (PE) programme in improving self-management in patients newly diagnosed with rheumatoid arthritis (RA). This was a parallel, open-label, two-armed, randomized controlled trial with superiority design. Patients from five rheumatology clinics were randomized into digital PE (intervention) or face-to-face PE (control). The primary outcome was self-efficacy, measured by average difference in the Rheumatoid Arthritis Self-Efficacy (RASE) score from baseline to month 12. Secondary outcomes were RA knowledge, health literacy, adherence and quality of life. Healthcare utilization data and digital PE programme usage were recorded. Self-efficacy, knowledge and health literacy data were analysed using mixed-effects repeated measures modelling; adherence using logistic regression, and quality of life and healthcare utilization using descriptive statistics with the Wilcoxon rank-sum test. Of the 180 patients randomized (digital PE, n = 89; face-to-face PE, n = 91), 175 had data available for analysis. Median age was 59.0 years and 61% were women. The average difference in self-efficacy between groups from baseline to month 12 was significant by a -4.34 difference in RASE score, favouring the intervention group (95% CI: -8.17 to -0.51; P = 0.026). RA knowledge, health literacy and quality of life showed minor improvements over time but no difference between groups, except out-patient clinic contacts, which were fewer in the intervention group. The findings suggest that digital PE is effective in improving self-efficacy and therefore self-management in patients with early RA. This intervention has potential to lower healthcare costs by decreasing out-patient clinic contacts. clinicaltrials.gov, NCT04669340.

Takotsubo Cardiomyopathy: Patients Characteristics, Mortality, and Clinical Significance of Left Ventricular Outflow Tract Gradient, Retrospective Study.

Takotsubo cardiomyopathy (TC) is a reversible left ventricular systolic dysfunction with apical ballooning. Left ventricular outflow tract (LVOT) obstruction may develop in these cases due to hyperdynamic state of the left ventricle. Limited data are available on the prevalence of LVOT gradient in TC and its association with patient outcomes and mortality. Data were collected retrospectively for patients diagnosed with TC in a single tertiary center, demographic information, blood analysis results, and imaging finding including ejection fraction, and LVOT gradient was obtained from medical records. Additionally, medical treatment and outcome during hospitalization were extracted. Follow-up was conducted through cardiology clinic or phone contact. A total of 59 patients diagnosed with TC were reviewed during hospitalization, and 40 patients were followed up after discharge by phone contact and cardiology clinic. Most patients were female (91.5%), and nonsignificant coronary artery disease was present in 16.9% of patients. Approximately two-third of the patients had a reduced ejection fraction on admission, and only two patients (5.4%) continued to have reduced ejection fraction on echocardiography follow-up within a period of 2-14 days. LVOT gradient was present in 17 patients (28.5%); patients with preserved ejection fraction had a higher probability of having an LVOT gradient. However, there was no association between LVOT gradient and shock or mortality. Four patients (6.7%) experienced 30-day mortality, while all-cause mortality was reported in eight patients (13.5%) over the follow-up period (mean (±SD) 20.8 months ± 16.2). LVOT obstruction may occur in TC patients; it has no correlation with shock or mortality. However, determining whether there is a gradient is important for deciding on specific treatment approach.

Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery.

Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care. This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers. This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers. Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Predicting Caregiver Communications in a Geriatric Clinic.

The current study evaluated the use of a machine learning model to determine benefit of medical record variables in predicting geriatric clinic communication requirements. Patient behavioral symptoms and global cognition, medical information, and caregiver intake assessments were extracted from 557 patient records. Two independent raters reviewed the subsequent 12months for documented (1) incoming caregiver contacts, (2) outgoing clinic contacts, and (3) clinic communications. Random forest models' average explained variance in training sets for incoming, outgoing, and clinic communications were 7.42%, 3.65%, and 6.23%, respectively. Permutation importances revealed the strongest predictors across outcomes were patient neuropsychiatric symptoms, global cognition, and body mass, caregiver burden, and age (caregiver and patient). Average explained variance in out-of-sample test sets for incoming, outgoing, clinic communications were 6.17%, 2.78%, and 4.28%, respectively. Findings suggest patient neuropsychiatric symptoms, caregiver burden, caregiver and patient age, patient body mass index, and global cognition may be useful predictors of communication requirements for patient care in a geriatric clinic. Future studies should consider additional caregiver variables, such as personality characteristics, and explore modifiable factors longitudinally.

Systematic Identification of Copositivity Groups in Standard Series Patch Testing Through Hierarchical Clustering

Patients are frequently copositive for multiple allergens simultaneously, either due to chemical similarity or simultaneous sensitization. A better understanding of copositivity groups would help guide contact avoidance. To use patient data to systematically determine copositivity groups in the Mayo Clinic Standard Series. In this retrospective cross-sectional analysis, the Mayo Clinic patch test database was queried for pairwise copositivity rates in the 80 allergen Mayo Clinic Standard Series between 2012 and 2021. Data were collected from 3 tertiary care sites of the Mayo Clinic Contact Dermatitis Group and a total of 5943 patients were included, comprising all patients undergoing patch testing to the Mayo Clinic Standard Series allergens. Copositivity rates between every 2 allergens in the 80-allergen Mayo Clinic Standard Series were estimated. After background correction, copositivity rates were analyzed using unsupervised hierarchical clustering to systematically identify copositivity groups in an unbiased manner. Overall, 394 921 total patches were applied to 5943 patients (4164 [70.1%] women, 1776 [29.9%] men, with a mean [SD] age of 52.3 [18.8] years ), comprising 9545 positive reactions. After background correction based on overall positivity rates, hierarchical clustering revealed distinct copositivity groups. Many were supported by prior literature, including formaldehyde releasers, cobalt-nickel-potassium dichromate, acrylates, 3-dimethylaminopropylamine-amidoamine-oleamidopropyl dimethylamine, alkyl glucosides, budesonide-hydrocortisone-17-butyrate, certain fragrances, compositae-sesquiterpene lactone mix, mercapto mix-mercaptobenzothiazole, carba mix-thiuram mix, and disperse orange-p-phenylenediamine. However, novel associations were also found, including glutaraldehyde-sorbitan sesquioleate, benzalkonium chloride-neomycin-bacitracin, bronopol-methylchloroisothiazolinone-methylisothiazolinone, and benzoic acid-iodopropynyl butylcarbamate. This retrospective cross-sectional analysis found that copositivity rates varied between allergens; allergens with extremely high positivity rates demonstrated nonspecific copositivity to multiple other allergens. Background correction based on positivity rates followed by hierarchical clustering confirmed prior known copositivity groups, contaminants and/or excipients leading to copositivity, and novel associations to guide contact avoidance.

Implications of Contact Days in the Treatment of Relapsed Refractory Diffuse Large B-Cell Lymphoma.

This commentary remarks on a recently published study assessing clinic contact days for patients enrolled in the Canadian Cancer Trials Group LY.12 clinical trial.

Uptake of Cardiac Rehabilitation in Te Whatu Ora – Counties Manukau During the Pandemic

Cardiac rehabilitation (CR) is an evidence-based range of interventions to support people with several cardiac issues. The impact of the COVID-19 pandemic created many challenges for health services and communities. Using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZAC-QI) CR database this study tracked referral, mode, and level of engagement from 2013 to 2023. Over 10 years, 9,134 referrals were identified, with a steadily decreasing number every year (1,040 in 2023 vs 672 in 2022; 35% decrease). The majority (70%) was male; mean age for males was 66 years, for females 67 years; and ethnicity was Māori 12%, Pacific 25%, Indian 12%, others 51%. Attendance of any program was 71%, with a 600% increase in clinics vs group interventions. The average uptake of the exercise program was 24%; Māori compared with Pacific and Euro/others (61% vs 71% vs 73%, p>0.001); and younger people (<60 years, 66% vs older >61 years, 73%, p>0.001) were least likely to attend, with no gender differences (male 71% vs Female 69%, p=NS). There has been a significant decline in CR referrals over the last 10 years, with a shift from group-based education to individualised clinic contacts. Uptake of exercise programs remains low. Novel interventions to support Māori and younger patients have been implemented.

A primary care delivered, technology supported lifestyle program for Type 2 Diabetes Management: An evaluation of changes in metabolic health, feasibility, and acceptability – A pilot interventional study protocol

BackgroundType 2 Diabetes (T2D) is associated with significant health complications and socioeconomic costs. Previous research conducted through an outpatient research facility demonstrated use of a low carbohydrate (LC) diet and exercise plan delivered in the format of an education book combined with use of real-time continuous glucose monitoring (RT-CGM) is an effective self-management intervention to improve weight and blood glucose management in patients with T2D. Primary health care remains the central access point for patient management of T2D, but General Practitioners (GPs) lack access to effective evidenced-based, self-management programs that can be prescribed to improve patient outcomes. MethodsA single-arm, within-participant pilot intervention study will be conducted to evaluate the changes in metabolic health, acceptability and feasibility of a prescriptive LC diet and lifestyle program combined with RT-CGM (LC-RTC) delivered via GP practices. Forty adults with T2D will be recruited from GP practices and prescribed the LC-RTC intervention for 12 weeks. Outcomes will be assessed at baseline and 12-weeks post intervention. Changes in metabolic health will be assessed by changes in glycosylated hemoglobin (primary outcome), body weight, blood pressure, blood lipids, and medication usage. Post-intervention, participants will complete questionnaires and participate in focus groups to explore their experience of the LC-RTC program including acceptance, perceived benefits/barriers, limitations, financial feasibility, intervention drop-out rates, participant and GP engagement with the program (clinic attendance and contacts made to clinic for program support) and RT-CGM use and wear time acceptance. GPs and clinical staff involved will participate focus groups to evaluate the perceived value and feasibility of the LC-RTC program. DiscussionThis trial will provide a powered evaluation of the changes in metabolic health, acceptability, and feasibility of the LC-RTC program for patients with T2D delivered via GP practices. Trial registrationANZCTR: 12622000635763 (Website Link to full registration: ANZCTR - Registration). Registered 29th April 2022. Overall trial status: Commenced; Recruitment Status: Commenced 1st May 2022, with 40 participants recruited as of 2nd May 2023 using a rolling recruitment approach.

Lean Six Sigma to reduce the acute myocardial infarction mortality rate: a single center study

PurposeCardiovascular diseases are the leading cause of death worldwide. In Italy, acute myocardial infarction (AMI) is a major cause of hospitalization and healthcare costs. AMI is a myocardial necrosis event caused by an unstable ischemic syndrome. The Italian government has defined an indicator called “AMI: 30-day mortality” to assess the quality of the overall care pathway of the heart attacked patient. In order to guarantee high standards, all hospitals had to implement techniques to increase the quality of care pathway. The aim of the paper is to identify the root cause and understand the mortality rate for AMI and redesign the patient management process in order to improve it.Design/methodology/approachA Lean Six Sigma (LSS) approach was used in this study to analyze the patient flow in order to reduce 30-days mortality rate from AMI registered by Complex Operative Unit (COU) of Cardiology of an Italian hospital. Value stream mapping (VSM) and Ishikawa diagrams were implemented as tools of analysis.FindingsProcess improvement using LSS methodology made it possible to reduce the overall times from 115 minutes to 75 minutes, with a reduction of 35%. In addition, the corrective actions such as the activation of a post-discharge outpatient clinic and telephone contacts allowed the 30-day mortality rate to be lowered from 16% before the project to 8% after the project. In this way, the limit value set by the Italian government was reached.Research limitations/implicationsThe limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.Practical implicationsThe LSS approach has brought significant benefits to the process of managing patients with AMI. Corrective actions such as the activation of an effective shared protocol or telephone interview with checklist can become the gold standard in reducing mortality. The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.Originality/valueLSS, applied for the first time to the management of cardiovascular diseases in Italy, is a methodology which has proved to be strategic for the improvement of healthcare process. The simple solutions implemented could serve as a guide for other hospitals to pursue the national AMI mortality target.

Oral Chemotherapy Metric Performance in Quality Oncology Practice Initiative Practices: Updated Trends and Analysis.

Oral chemotherapy performance measures were first introduced into ASCO's Quality Oncology Practice Initiative (QOPI) in 2013. This study examined performance on these measures among QOPI-participating practices and evaluated whether it differed among practices based on meeting QOPI Certification Program standards. A total of 192 QOPI-participating practices (certified, n=50 [26%]; not certified, n=142 [74%]) reported performance on oral chemotherapy measures in 2017 and 2018. Inclusion was limited to practices reporting on ≥3 charts for ≥1 oral chemotherapy measure. Performance was defined as the percentage of charts examined that adhered to the measure. Descriptive analyses were used to characterize performance within and across practices, and mixed-effects logistic regression models were conducted to compare performance based on certification status. Median performance across practices for the 9 oral chemotherapy measures examined ranged from 44% (education before the start of treatment addressing missed doses, toxicities, and clinical contact instructions [composite measure]) to 100% (documented dose, documented plan, and education about toxicities). Certified practices were more likely to provide education about clinic contact instructions than noncertified practices (odds ratio, 4.87; 95% CI, 1.00-24.0). Performance on all other measures was not significantly associated with certification status. There is wide variability in quality related to performance on oral chemotherapy measures across all QOPI-participating practices, and several areas were identified in which administration of oral chemotherapy could be improved. Our findings highlight the need for the development and implementation of appropriate standards that apply to oral chemotherapy and address the complexities that set it apart from parenteral treatment.

Reevaluating Corticosteroid Classification Models in Patient Patch Testing

Individuals with allergic contact dermatitis to one topical corticosteroid may also react to other corticosteroids. Corticosteroid classification models have been proposed to predict such copositivity, recommend representative screening corticosteroids, and guide allergen avoidance. To use patient data to determine copositivity patterns between corticosteroids and evaluate against previous corticosteroid classification models. This qualitative study included a retrospective analysis of the Mayo Clinic Contact Dermatitis Group corticosteroid patch test data from 2010 to 2019. Among patients undergoing patch testing with the Mayo Clinic's standard or steroid series who consented to research participation, 5637 patients were included in the analysis. Copositivity rates were determined between corticosteroids and analyzed by hierarchical clustering for comparison to previous classification models. The frequency of patch test positivity to each of the analyzed corticosteroids was noted and compared with previously published patch test positivity rates. Copositivity rates between each pair of corticosteroids were determined, and overall copositivity patterns were analyzed and evaluated against known steroid classes. A total of 49 472 individual patches were applied to 5637 patients, testing 18 corticosteroids. Patch test positivity rates ranged between 0.3% and 4.7%. The fluocinonide positivity rate corresponded to the highest copositivity rate with other corticosteroids (mean [SD], 50.7% [26.1%]). Tixocortol-21-pivalate, 0.1%, and tixocortol-21-pivalate, 1%, positivity rates corresponded to the lowest copositivity rates (mean [SD], 4.1% [1.7%] and 3.6% [1.4%], respectively). Hierarchical clustering elucidated patterns that did not support previous corticosteroid classification models. In this qualitative study, copositivity rates were variable between corticosteroids, and overall patch test positivity for allergy to topical corticosteroids was rare. Previously published corticosteroid classifications are not supported by real patient-derived data and may not be accurate in predicting corticosteroid copositivity.

A Pragmatic Study on Nurse-Led Home Phototherapy

BACKGROUND Narrowband ultraviolet phototherapy is a safe and effective treatment option for chronic skin conditions. The requirements of clinic-based phototherapy can be burdensome, with home-based phototherapy as a reasonable alternative. OBJECTIVE This study aimed to analyze the effects of a nurse-led home phototherapy program and describe the clinical resources required. METHODS A pragmatic multicenter prospective observational cohort study was conducted from 2019 to 2021. Eighteen participants were enrolled in the program and followed for 9 months. Outcome measures included clearance rates, erythema incidence, Dermatology Life Quality Index, the burden of treatment scores, dermatologic medication usage, and clinic contacts. RESULTS Fourteen of the 18 patients (77.8%) reported high skin clearance. Mild erythema was common, moderate erythema was rare, and two episodes of severe erythema were recorded overall. Dermatology Life Quality Index and burden of treatment impact were minimal. Adjunct topical medications decreased by half. Nurses successfully reached participants up to the 3-month time point, with completed contacts decreasing over time. Unplanned contacts included phone calls and emails. CONCLUSION Dermatology nurses possess the skills needed to lead safe and effective home phototherapy programs. Although this pragmatic study was small, results are optimistic for the future of nurse-led home phototherapy.

Is it safe and rational to remove both lower third molars in one session? A randomised controlled trial to compare unilateral vs bilateral third molar extractions under local anaesthesia

Third molar extraction is one of the most common procedures in oral surgery. However, it is still unclear whether extracting the two lower third molars in two separate sessions or one appointment is preferable. This randomised controlled trial, including 100 patients, aimed to compare unilateral with bilateral lower third molar extraction under local anaesthesia. We recorded downtime, pain level, dysphagia, hypoesthesia, additional clinic contacts and group preference. In the bilateral study group, two patients preferred not to proceed after the first side (3.8%, n = 2/53). Thirteen patients (27.7%, n = 13/47) did not show up for the second operation in the control group. The mean sick leave duration was significantly lower in the bilateral study group (3.47 days) than in the unilateral control group (6.03 days, t-test: p-value<0.05). Patients with bilateral extraction did not report higher pain levels or more difficulties with swallowing than the unilateral control group. There was no significant difference between the groups regarding hypoesthesia and additional clinic contacts. Our randomised controlled trial could demonstrate that bilateral lower third molar extraction under local anaesthesia is safe and well accepted by patients. Two separate appointments were associated with higher pain levels, experiencing the pain twice, and the double number of days off work or school. Furthermore, bilateral procedures in a single appointment save resources, as only one surgical set and one sterilisation process are needed. In conclusion, based on our experience, we recommend offering bilateral extraction of the lower third molars in a single visit to reduce overall patients’ physical and psychological discomfort. Additionally, from a socio-economic perspective, workload and costs are lower for the health system - one single surgical set and sterilisation - and the society - half downtime.

Telehealth provider experience in reproductive endocrinology and infertility clinics during the COVID-19 pandemic and beyond

PurposeTo assess telehealth services offered by reproductive endocrinology and infertility specialists and to gauge provider experiences with incorporating telehealth into their practices.MethodsA 16-question web-based survey on use of telehealth was distributed to Society for Assisted Reproductive Technology (SART) clinics and to Society for Reproductive Endocrinology and Infertility (SREI) members. Clinic demographic data, telehealth descriptive data, and provider satisfaction with use of telehealth were assessed. Results were collected via Survey Monkey.ResultsA total of 1160 individuals (330 SART clinic contacts and 830 SREI members) were reached via email with an 18.6% (216) survey response rate. All respondents indicated that they offer telehealth visits. Several telehealth platforms were used, with Zoom (62.7%) and telehealth through the clinic’s electronic medical record platform (34.8%) being the most common. The majority of participants (87.0%) anticipate they will offer telehealth visits after the COVID-19 pandemic. Roughly two-thirds (64.4%) of respondents anticipate fewer telehealth visits after the pandemic because of logistics, cost, and patient/provider preference. Nearly all providers are either “very satisfied” (66.2%) or “somewhat satisfied” (31.0%) with telehealth overall.ConclusionTelehealth enabled safe patient-provider interactions throughout the COVID-19 pandemic. While only one-third of survey respondents offered telehealth services before the pandemic, nearly all providers express satisfaction with telehealth and anticipate they will offer telehealth services henceforth.

Thromboembolic Risk in Patients With Pneumonia and New-Onset Atrial Fibrillation Not Receiving Anticoagulation Therapy

New-onset atrial fibrillation (AF) is commonly reported in patients with severe infections. However, the absolute risk of thromboembolic events without anticoagulation remains unknown. To investigate the thromboembolic risks associated with AF in patients with pneumonia, assess the risk of recurrent AF, and examine the association of initiation of anticoagulation therapy with new-onset AF. This population-based cohort study used linked Danish nationwide registries. Participants included patients hospitalized with incident community-acquired pneumonia in Denmark from 1998 to 2018. Statistical analysis was performed from August 15, 2021, to March 12, 2022. New-onset AF. Thromboembolic events, recurrent AF, and all-cause death. Estimated risks were calculated for thromboembolism without anticoagulation therapy, new hospital or outpatient clinic contact with AF, initiation of anticoagulation therapy, and all-cause death at 1 and 3 years of follow-up. Death was treated as a competing risk, and inverse probability of censoring weights was used to account for patient censoring if they initiated anticoagulation therapy conditioned on AF. Among 274 196 patients hospitalized for community-acquired pneumonia, 6553 patients (mean age [SD], 79.1 [11.0] years; 3405 women [52.0%]) developed new-onset AF. The 1-year risk of thromboembolism was 0.8% (95% CI, 0.8%-0.8%) in patients without AF vs 2.1% (95% CI, 1.8%-2.5%) in patients with new-onset AF without anticoagulation; this risk was 1.4% (95% CI, 1.0%-2.0%) among patients with AF with intermediate stroke risk and 2.8% (95% CI, 2.3%-3.4%) in patients with AF with high stroke risk. Three-year risks were 3.5% (95% CI, 2.8%-4.3%) among patients with intermediate stroke risk and 5.3% (95% CI, 4.4%-6.5%) among patients with high stroke risk. Among patients with new-onset AF, 32.9% (95% CI, 31.8%-34.1%) had a new hospital contact with AF, and 14.0% (95% CI, 13.2%-14.9%) initiated anticoagulation therapy during the 3 years after incident AF diagnosis. At 3 years, the all-cause mortality rate was 25.7% (95% CI, 25.6%-25.9%) in patients with pneumonia without AF vs 49.8% (95% CI, 48.6%-51.1%) in patients with new-onset AF. This cohort study found that new-onset AF after community-acquired pneumonia was associated with an increased risk of thromboembolism, which may warrant anticoagulation therapy. Approximately one-third of patients had a new hospital or outpatient clinic contact for AF during the 3-year follow-up, suggesting that AF triggered by acute infections is not a transient, self-terminating condition that reverses with resolution of the infection.

Factors Associated with Time to Receiving Gender-Affirming Hormones and Puberty Blockers at a Pediatric Clinic Serving Transgender and Nonbinary Youth.

To describe barriers to care for a cohort of transgender and nonbinary (TNB) youth and examine factors associated with delays in receiving puberty blockers (PBs) or gender-affirming hormones (GAHs). We used longitudinal data from a prospective cohort of TNB youth seeking care at a multidisciplinary pediatric gender clinic between August 2017 and June 2018. We calculated the time between (i) initial clinic contact, (ii) phone intake, (iii) first medical appointment, and (iv) initiating PBs/GAHs. We estimated Kaplan-Meier curves for each time-to-care interval and used Cox regression models to estimate hazard ratios (HRs) for factors hypothesized to be barriers and facilitators of care. Our cohort included 104 youth aged 13-20 years. The median time from contacting the clinic to initiating PBs/GAHs was 307 days (range, 54-807). Lower income level, Medicaid insurance, and lack of family support were associated with longer times from contacting the clinic to completing the first medical appointment. In addition, older youth experienced longer times to first medical appointment relative to youth aged 13-14 years. Youth younger than 18 years of age who did not complete a mental health assessment before their first medical appointment experienced delays from first medical appointment to initiating PBs/GAHs (HR=0.44, 95% confidence interval, 0.22-0.88). Certain subsets of youth disproportionately experienced delays in receiving gender-affirming medications, and these factors varied by stage of care engagement. Given the association between gender-affirming care and improved mental health, identifying sociostructural and clinic-level barriers to care is critically important to facilitating more equitable access.

A cohort study of the impact of COVID-19 on the quality of life of people newly diagnosed with dementia and their family carers.

IntroductionCOVID‐19 has impacted people with dementia and their family carers, yet little is known about effects on overall quality of life.MethodsIn a UK cohort study, pre‐ and post‐pandemic data were collected from 114 carers and 93 recently diagnosed people with dementia. Latent growth curve modeling examined change in quality of life.ResultsCarers reported significant decline in quality of life, although no change was demonstrated by people with dementia. In multivariable analyses, higher levels of cognitive impairment, deprivation, study site, and lower number of memory clinic contacts were associated with greater decline in carer quality of life.DiscussionMaintaining life quality for people with dementia during the pandemic appears to have come at the expense of their family carers. This inequity has fallen hardest on those caring for people with more severe dementia, in deprived areas, and with least support from memory services. These effects may be prevented or reversed by post‐diagnostic care.

Two-Year Evaluation of the German Clinical Amyloidosis Registry

Introduction Currently there are no sufficient epidemiology data on systemic amyloidosis in Germany. Our aim was to collect epidemiological data on amyloidosis diseases to determine incidence and distribution of amyloidosis types in Germany. In addition, data on diagnosic pathways, demographic, clinical and biological factors, quality of life (Qol) and overall survival (OS) have been collected.Methods: The actual registry population consists of the first n=1000 reported cases of newly diagnosed amyloidosis patients between 4.1.18 - 21.11.19. Data cutoff of the analysis was June 30, 2021. Patients were included in the registry by two main ways: personal presentation at the amyloidosis outpatient clinic or phone contact of the attending physician to the Amyloidosis Center. Inclusion criteria were either a Congo Red positive tissue sample or unequivocal findings in bone scintigraphy (ATTR amyloidosis). Patients were contacted every 6 months to obtain QoL data using EORTC QLQ-C30, EQ-5D-5L and SF36-v2 questionnaires. This registry was financially supported by Prothena.Results: During this time period 963 of the first 1000 reported newly diagnosed patients (37 pts. did not fulfil inclusion criteria and were excluded) were evaluated mainly through the amyloidosis outpatient clinic (n=581, 60.3%). Seventy-three percent of cases were male (n=706). The median age at diagnosis was 71 years and differed between the AL pts.(65,5 years) and ATTRwt (78 years) patients. The subgroup distribution was as follows: 438 (45,5%) AL pts., 318 (33%) ATTRwt pts., 35 (3,6%) ATTRv pts, 60 (6,2%) ATTR of unknwon subtype, 66 (6,8%) local amyloidosis, 30 (3,1%) AA amyloidosis, 12 (1,2%) others and 4 (0,4%) not typed. Diagnosis was confirmed by biopsy in 88% and in 12% by bone scintigraphy. The most commonly involved organs were heart (n=733, 76,1%) and kidney (n=305, 31,7%). Cardiac staging systems were used for systemic AL (Kumar et al., 2014) with heart involvement and ATTR amyloidosis (Gillmore et al., 2018). Data on survival were available in all cases (median follow-up 27 months). During the observation time 249 patients died (60 ATTRwt and 153 AL pts., 36 other, figure). The most frequent cause of death was amyloidosis itself (n=191, 76,7%). Seven (2,8%) patients died due to therapeutic complications. Compared to ATTRwt patients with cardiac AL amyloidosis had a higher hazard to die, 1 year survival was 78.96% (95% CI 75.23% - 82.88%) compared to 94.30% (95% CI 91.80% - 96.90%), respectively. In multivariate analysis (including age, cardiac staging systems and time from symptoms to diagnosis) factors associated with worse OS were increasing age for AL pts. (HR 1.04, p<0,001 for AL, and highest cardiac stage (HR 2.33, p=0,001 for AL and 5.69, p<0,001 for ATTRwt).Conclusion: The first 2 years of the German clinical amyloidosis registry have been successful to generate valuable clinial data for all types of amyloidosis from newly diagnosed patients. Subtyping the amyloid precursor protein was successful in nearly all patients. The most common form is AL followed by ATTRwt amyloidosis. Heart involvment was very common and pts. were mostly in advanced cardiac stage. Main cause of death was amyloidosis related. In 2020 we have started an extended registry (financially supported by Janssen) including anonymized biopsy reports from reference pathologists. With this approach we will probably obtain more precise data on incidence in Germany. [Display omitted] DisclosuresHegenbart: Alnylam: Honoraria; Akcea: Honoraria; Pfizer: Consultancy, Honoraria; Janssen: Consultancy, Research Funding; Prothena: Research Funding. Carpinteiro: Janssen: Honoraria; BMS: Honoraria; GSK: Honoraria; Amgen: Honoraria; Takeda: Honoraria. Müller-Tidow: Pfizer: Research Funding; Bioline: Research Funding; Janssen: Consultancy, Research Funding. Schönland: Janssen: Honoraria, Other: Travel grants, Research Funding; Prothena: Honoraria, Other: Travel grants; Pfizer: Honoraria; Takeda: Honoraria, Other: Travel grants; Sanofi: Research Funding.