Clinical Consultation Research Articles

Management of Prenatal Expanded Genetic Carrier Screening Results for Autosomal Recessive Sensorineural Hearing Loss

AbstractObjectiveExpanded carrier screening (ECS) identified couples at‐risk to have a baby with an autosomal recessive genetic condition. Several genes implicated in sensorineural hearing loss (SNHL) are included in prenatal or preconception genetics ECS testing. Early identification of SNHL risk may enable prognostication of hearing loss, early educational intervention, and minimization of unnecessary diagnostic testing. We sought to describe cases where ECS enabled early SNHL‐risk identification.Study DesignRetrospective chart review.SettingMaternal‐Fetal Care Center and Otolaryngology department at an academic tertiary hospital.MethodsMedical records of parent‐infant dyads with positive ECS results for variants in autosomal recessive SNHL genes were reviewed. Data regarding genetic diagnostic testing, newborn hearing screening, time to HL diagnosis, audiological evaluation, and clinical consultations were compiled.ResultsFifteen pregnant with positive ECS results for SNHL were referred for consultation with a pediatric otolaryngologist and genetic counselor. Generally, these couples were highly educated and adequately insured. 14 had pathogenic variants for GJB2 and 1 for USH2A. Four couples pursued prenatal genetic diagnosis via amniocentesis; 11 couples deferred genetic testing to the postnatal period or waited for initial hearing evaluation. Six babies inherited biallelic GJB2 mutations. Four were found to have SNHL on ABR by age 5 weeks and received follow‐up management, 1 had a normal hearing evaluation despite being gene‐positive, and 1 was lost to follow‐up before hearing evaluation.ConclusionsCarrier screening and confirmatory prenatal or neonatal genetic testing provided considerable lead time for early audiometric testing and appropriate intervention services including hearing aid fitting.

A review of clinical ethics consultations in a regional healthcare system over a two-year timeframe

BackgroundClinical Ethics Consultations (CECs) are used by healthcare systems to offer healthcare practitioners a structured level of support to approach ethical questions. The objective of this study was to detail the elements of surveyed CECs and offer guidance in the approach to future ethics consultations at a regional healthcare system.MethodsThis cohort study has a qualitative and quantitative retrospective approach, surveying ethics consultations through the dates of 4/27/22 to 4/26/24. A documentary sheet was created, and information was entered via online data-gathering forms. The cases are from a range of specialties within a regional healthcare system servicing Minnesota, Wisconsin, and North Dakota.Results103 CECs were performed within the study period across the regional healthcare system. Consultations were identified through retrospective review of the internal CEC database, and patient information was collected through the medical record. Decision-making was often performed by a substitute decision-maker (N = 54), occurring in 70.1% of cases with known decision makers. CECs were documented in an ethics-specific note in the patient medical record in 37 of 82 (45.1%) documented patient cases. It was common for physicians to mention the ethics consultation in their patient notes, occuring in 51 of 82 (62.2%) of documented patient cases. Age was recorded in 92.0% (N = 91) of unique patient cases; the median age was 62 years. Ethical questions concerning end-of-life care were the most common cause for consultation (N = 35, 34%), and CECs were most commonly requested in general medicine or hospitalist departments (N = 38, 45.2%). Most consultations resulted in resolution at time of initial consultation with the ethics call team.ConclusionsRecommendations for increased frequency and timing of policy review are given based on the results of the data presented. Using interpretation of the CECs in this study, we offer recommendations towards the use and documentation of ethics consultations in the era of open notes, open the door towards areas of future research, and ultimately promote use of CECs for more favorable patient outcomes.

The role of illness perception in the physical activity domain of health-promoting lifestyle among patients with non-communicable diseases: A systematic review

Background The global mortality caused by non-communicable diseases is on the rise. Health-promoting lifestyles are among the most effective approaches, yet the physical activity domain consistently scores the lowest. Physical activity is linked to individual behaviour and influenced by numerous factors. Illness has been identified as a key factor in behavioural change. Therefore, the primary purpose of this review was to investigate the role of illness perception in the physical activity domain among patients with non-communicable disease. Method This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A literature search was conducted across three scientific databases (Scopus, PubMed, and Web of Science), targeting original articles published in English between 2014 and 2024. The quality of the eligible articles was assessed using the Joanna Briggs Institute Critical Appraisal tools. The findings were synthesised through content analysis. Results A total of 17 studies were included, identifying both the direct and indirect effects of illness perception variables as a whole or in their respective dimensions. The illness perception variable has demonstrated a significant positive and negative relationships with the physical activity domain. Limitation The majority of the included studies had a cross-sectional design. Therefore, the evidence quality was relatively low and exhibited a high risk of bias. Furthermore, there was language bias as only English-language publications were selected. Conclusion The findings of this review will serve as a guide for healthcare providers in enhancing physical activity adherence among patients with non-communicable diseases through an illness perception approach. This approach can be integrated into clinic consultations and intervention programmes. Future studies are warranted to evaluate the effectiveness of the illness perception approach in promoting physical activity adherence.

Exploring the correlation between airborne pollen levels and respiratory conditions in Jaipur, India

ABSTRACT Airborne pollen, a significant natural pollutant, restricts outdoor activities and impacts quality of life for sensitive individuals with pulmonary disorders. This study examines trends in airborne pollen concentrations and explores whether air pollution, pollen concentration, or both impact patient counts. The annual pollen trend in Jaipur shows peaks in pollen concentration in March (due to trees, 66%), September (due to weeds, 45%), and December (due to grass, 50%). Among the fifteen taxa examined, Holoptelea integrifolia is the largest pollen emitter in Jaipur, followed by Poaceae, among others. The count of patients arriving for clinical consultations in a hospital shows a strong and positive correlation with weed (Asteraceae spp. and Argemone mexicana) and grass pollen. A linear regression equation is developed (R2 value = 0.835) for forecasting consulting patient counts based on Cassia siamea pollen concentration. This can assist hospital administration in resource management, especially during peak allergy seasons.

Utilization and Evaluation of Ethics Consultation Services in Neonatal Intensive Care

Background: The opportunities of perinatal medicine have improved, but this has also been accompanied by increasing ethical challenges. Clinical ethics consultation services (CEC) could support medical teams facing these. However, nothing is currently known about the availability, utilization and evaluation of CEC in German neonatology units. Methods: This study was designed as a national, descriptive, mixed quantitative–qualitative questionnaire study. The head physicians of the pediatric departments and the heads (medical and nursing) of the corresponding neonatal intensive care units of the 213 German perinatal centers were asked to participate. Results: Ninety percent of the respondents (responding rate 24.4–38.0%) stated that CEC are established and available. However, utilization is rather low [rarely N = 40 (54.1%), never N = 12, (16.2%), occasionally N = 19 (25.7%)], although it was rated as very helpful. There was a significant correlation between utilization and perceived general usefulness (r = 0.224, p = 0.033) and support (r = 0.41, p < 0.001); whereas evaluations differed significantly between professional groups (t = −2.298, p = 0.23, Cohen’s d = 0.42). Conclusions: The contradiction between the low utilization despite positive evaluations could be related to perceived hurdles. These and the different perceptions within the professional groups give rise to the consideration of whether alternative approaches, e.g., liaison services, would be preferable in neonatology.

Accuracy is inaccurate: Why a focus on diagnostic accuracy for medical chatbot AIs will not lead to improved health outcomes.

Since its launch in November 2022, ChatGPT has become a global phenomenon, sparking widespread public interest in chatbot artificial intelligences (AIs) generally. While not approved for medical use, it is capable of passing all three United States medical licensing exams and offers diagnostic accuracy comparable to a human doctor. It seems inevitable that it, and tools like it, are and will be used by the general public to provide medical diagnostic information or treatment plans. Before we are taken in by the promise of a golden age for chatbot medical AIs, it would be wise to consider the implications of using these tools as either supplements to, or substitutes for, human doctors. With the rise of publicly available chatbot AIs, there has been a keen focus on research into the diagnostic accuracy of these tools. This, however, has left a notable gap in our understanding of the implications for health outcomes of these tools. Diagnosis accuracy is only part of good health care. For example, crucial to positive health outcomes is the doctor-patient relationship. This paper challenges the recent focus on diagnostic accuracy by drawing attention to the causal relationship between doctor-patient relationships and health outcomes arguing that chatbot AIs may even hinder outcomes in numerous ways including subtracting the elements of perception and observation that are crucial to clinical consultations. The paper offers brief suggestions to improve chatbot medical AIs so as to positively impact health outcomes.

Effectiveness of telephone clinics for assessment of new onset chest pain - a retrospective single-centre observational study

Abstract Background The COVID-19 pandemic led to a significant shift in the way clinical consultations are conducted with a rapid transition towards remote consultations (teleclinics). Although face-to-face (F2F) clinics are being re-introduced in the post-pandemic era, a significant proportion of clinics continue to run remotely. Despite the inability to physically examine the patient, remote clinics have notable advantages such as increased accessibility and flexibility for both the clinician and the patient. Purpose As the healthcare model moves increasingly towards a hybrid system where both F2F and teleclinics coexist, we sought to analyse the differences in practice between the two groups. Methods This single-centre retrospective analysis of patients referred to specialist cardiology services with NOCP compared face-to-face (F2F) consultations with teleclinic consultations. 70 patients were randomly selected in each category from a list of patients with NOCP that were referred to a tertiary cardiac centre from January to December 2021. Teleclinic appointments were conducted via telephone while F2F clinics had the patients visit the hospital for their appointments. Results The main findings are tabulated in Table 1. The samples for the two categories were evenly matched. Teleclinic appointments had a significantly reduced waiting time compared to F2F clinic (4 vs 6 weeks, p= 0.0009). As expected, the teleclinic group had reduced access to examination findings such as blood pressure, heart rate, and ECG. There was no significant difference in an initial working diagnosis of typical angina between the F2F group and the teleclinic group (30% and 25.7% respectively, p=0.706). However, patients in the F2F group were more likely to have anti-anginal therapy commenced compared to teleclinic group (50% vs 27.1% respectively, p=0.0089) following initial clinic review. Also, they were more likely to undergo an invasive coronary angiogram (30% vs 12.9% in F2F and teleclinic groups respectively, p=0.0224). However, this did not lead to a significant increase in PCIs performed in the F2F group. More patients had non-invasive tests requested in the teleclinic group compared to the F2F clinic group (62.9% vs 50% respectively, p=0.17) although this was not significant the median number of total investigations requested were the same in both the group. Conclusion Telephone consultations appear to be a reasonable alternative to F2F consultations with reduced waiting times and no significant impact on investigations ordered. However, lack of key examination findings may have hampered prescription of anti-anginal medications. Provisions such as readily available access to GP health care records on examination findings along with a streamlined remote prescription system can help overcome reluctance to prescribe antianginals. Further research is needed to assess clinical outcomes of teleclinic consultations.Table 1

Association of adverse childhood experiences with adult-onset cardiometabolic conditions and prescription medicine use

Abstract Association of adverse childhood experiences with adult-onset cardiometabolic conditions and prescription medicine use Background and importance Adverse childhood experiences are potentially preventable and traumatic events that occur during childhood. Childhood exposure to trauma is highly prevalent and adults who had adverse childhood experiences are at increased risk of developing physical conditions. However, effect of adverse childhood experiences on health outcomes remains underrecognized. Aim Here, we aimed to measure the association of cumulative adverse childhood experience with adult physical condition and use of prescription medicines in general population. Methods We conducted a cross-sectional analysis using the population-based health study including 21083 participants at age 40 years or older. Self-reported adverse childhood experiences before age at 18 years, present or previous cardiometabolic conditions, and present or previous use of medications prescribed for cardiometabolic conditions were used in our analysis. Cox proportional hazards regression was used to estimate age, sex, smoking, education, and income-adjusted risk of cardiometabolic condition and prescription medicine use after adverse childhood experiences. Association of multimorbidity and using multiple prescription medicines with adverse childhood experience was analyzed using generalized linear model with ordinal classification. Results We found that having a history of adverse childhood experience was associated with increased risk of subsequent cardiometabolic conditions; hazard ratios ranged from 1.117 (95% CI, 1.054 – 1.185) to 1.341 (95% CI, 1.181 – 1.522). Furthermore, adverse childhood experience was associated with multimorbidity of cardiometabolic conditions (odds ratio [OR], 1.195; 95% CI, 1.117 – 1.279) and increased risk of using multiple prescription medicines (OR, 1.131; 95% CI, 1.057 – 1.210). Notably, we observed the dose – effect relationships of cumulative adverse childhood experience to the increased risk of 5 among 6 cardiometabolic conditions and to the increased risk of using 4 among 6 prescription medicines. Furthermore, cumulative adverse childhood experience had the dose – effect associations with multimorbidity of cardiometabolic conditions (ORs ranged from 1.120 [95% CI, 1.033 – 1.214] to 1.526 [95% CI, 1.276 – 1.825]) and using multiple prescription medicines (ORs are 1.393 [95% CI, 1.195 – 1.624] and 1.572 [95% CI 1.315 1.879]). Conclusions and relevance: Our findings implicate cumulative adverse childhood experience as a risk factor for later cardiometabolic conditions and use of medicines prescribed for cardiometabolic conditions. Our results are significant by suggesting inquiry into adverse childhood experience exposure during clinical consultations, services to alleviate the burden and increasing resilience in addition to strategies aimed at prevention of cardiometabolic conditions might improve health outcomes.

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

Abstract Background Acute chest pain in primary care often results in defensive and unnecessary hospital referrals due to the limited ability to rule out an acute myocardial infarction (AMI) outside of hospital. In a previous prospective observational study (OUT-ACS; One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome), we demonstrated that the ESC 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) would be safe and cost-effective if implemented to assess low-risk patients with chest pain in emergency primary care. Purpose We evaluated the real-world applicability, personnel adherence, and disposition of low-risk patients with chest pain following the implementation of the ESC 0/1-hour algorithm in emergency primary care. Methods In April 2023, the ESC 0/1-hour algorithm for hs-cTnT was implemented at a large emergency primary care clinic in Norway. The clinic is located close to a hospital, enabling the patient to wait at the clinic while blood samples are analysed for hs-cTnT at the hospital laboratory. For the following six months, all patients ≥18 years with acute non-traumatic chest discomfort, offered hs-cTnT measurements at the clinic, were anonymously registered, including their discharge diagnoses and disposition from the clinic. By applying the ESC 0/1-hour algorithm, patients were assigned to rule-out, rule-in or further observation. Patients in the observation group were offered a 4-hour hs-cTnT measurement before a final decision. Results During the six-month period, 10.3% (n=3,053/29,631) of the clinic's consultations involved chest complaints. Hs-cTnT measurements were conducted in 32.6% (n=995/3,053) with a median age of 58 years (IQR 45-68), 50.6% being female. A single hs-cTnT <5 ng/L, sampled ≥3 hours since symptom onset, triaged 24.1% (n=240/995) of the patients towards the rule-out group, increasing to 63.8% after adding a 1-hour measurement. In the rule-in group (n=42/995, 4.2%), 16 patients were diagnosed with an AMI. The intermediate observation group (n=318/995, 32.0%, 4 AMIs) was reduced to 23.0 % after a 4-hour hs-cTnT measurement. Healthcare personnel adhered well to the algorithm, with a median sampling interval of 63 minutes (IQR 60-66) and 4.5 hours (IQR 4.1-5.5) for the 1- and 4-hour measurements, respectively. The algorithm was misinterpreted or overruled in 8.8% of the cases. Ultimately, only 14.8% required hospital transfer following troponin assessment at the clinic. The remaining patients were sent home or managed in the outpatient setting. Conclusions The OUT-ACS strategy, utilizing a 0/1/4-hour algorithm for hs-cTnT measurements in emergency primary care, is safe, effective and applicable, and the strategy contributes to reduced hospital referrals for low-risk patients with chest pain.0/1/4-hour algorithm for hs-cTnTDisposition

Artificial intelligence versus human touch: can artificial intelligence accurately generate a literature review on laser technologies?

To compare the accuracy of open-source Artificial Intelligence (AI) Large Language Models (LLM) against human authors to generate a systematic review (SR) on the new pulsed-Thulium:YAG (p-Tm:YAG) laser. Five manuscripts were compared. The Human-SR on p-Tm:YAG (considered to be the "ground truth") was written by independent certified endourologists with expertise in lasers, accepted in a peer-review pubmed-indexed journal (but not yet available online, and therefore not accessible to the LLMs). The query to the AI LLMs was: "write a systematic review on pulsed-Thulium:YAG laser for lithotripsy" which was submitted to four LLMs (ChatGPT3.5/Vercel/Claude/Mistral-7b). The LLM-SR were uniformed and Human-SR reformatted to fit the general output appearance, to ensure blindness. Nine participants with various levels of endourological expertise (three Clinical Nurse Specialist nurses, Urology Trainees and Consultants) objectively assessed the accuracy of the five SRs using a bespoke 10 "checkpoint" proforma. A subjective assessment was recorded using a composite score including quality (0-10), clarity (0-10) and overall manuscript rank (1-5). The Human-SR was objectively and subjectively more accurate than LLM-SRs (96 ± 7% and 86.8 ± 8.2% respectively; p < 0.001). The LLM-SRs did not significantly differ but ChatGPT3.5 presented greater subjective and objective accuracy scores (62.4 ± 15% and 29 ± 28% respectively; p > 0.05). Quality and clarity assessments were significantly impacted by SR type but not the expertise level (p < 0.001 and > 0.05, respectively). LLM generated data on highly technical topics present a lower accuracy than Key Opinion Leaders. LLMs, especially ChatGPT3.5, with human supervision could improve our practice.

Real world economic evaluation of CT-FFR in patients with suspected coronary artery disease

Abstract Background Incorporation of CT-derived fractional flow reserve (CT-FFR) enhances the precision of Coronary CT Angiography (CCTA) to detect hemodynamically significant coronary artery disease (CAD). However, the financial consequences remain unclear. Purpose Our objective is to assess the economic implications of CT-FFR in the Dutch Healthcare system. Methods This retrospective, single-center cost effectiveness analysis includes patient data of a previously published study assessing the impact of routine CT-FFR availability on clinical management. We collected medical resource use for both diagnostic and therapeutic cardiovascular care with a follow-up duration of 1 year. Costs of CT-FFR analysis were set at €1000, its current price for Dutch hospitals. Median total costs at were compared using the Wilcoxon rank sum test, including a sensitivity analysis in which cost estimations (without registered maximum tariffs) were increased or decreased with 10%. Results A total of 360 patients, classified as having low to intermediate risk of CAD, were enrolled in the study – 224 in the CCTA group and 136 in the CT-FFR group. In addition to undergoing more (invasive) diagnostic testing and revascularization procedures over the studied period, patients in the CCTA-group had more outpatient clinic consultations (p&amp;lt;0.001), presented more frequently to the emergency department (p=0.035) and spend more nights in the hospital (p=0.11). Median costs were €3.347 (IQR €1.066 – €4.862) in the CCTA-group and €1.436 (IQR €1.362 - €3.943) in the CT-FFR group (p=0.091). Increasing cost estimation with 10% revealed a median of €3.431 in the CCTA-group versus €1.479 in the CT-FFR group (p=0.078), decreasing with 10% showed median costs of €3.263 in the CCTA-group and €1.392 in the CT-FFR group (p=0.118). In our sample, CT-FFR guided care would have been significantly cheaper than CCTA-guided care at or below a market price of €770. Conclusion Despite the significant reduction in additional diagnostic testing and hospital visits in the CT-FFR group, CT-FFR guided care was not cheaper than CCTA-guided care at its current market price of €1.000. Economic cost-effectiveness would have occurred from a price of €770 per analysis. The large difference between medians suggests that the lack of significance might partially be attributed to insufficient power in this relatively small sample size. Additionally, this study did not account for costs associated with loss of productivity and quality of life. However, less additional diagnostic testing, less revascularization procedures and less hospital consultations and admissions leads to reduction in hospital resource consumption and patient burden, which is an important advantage of CT-FFR as the number of referred patients increases yearly.

Evaluating Accuracy of AI-Generated Travel Vaccine Recommendations: GPTs in Public Health

Abstract Introduction Artificial intelligence (AI), particularly generative pre-trained transformers (GPTs), holds promise for enhancing public health strategies like travel vaccine recommendations. This pilot study evaluated GPTs’ accuracy in delivering tailored vaccine advisories compared to standards set by public health professionals. Integrating AI’s data analysis capabilities into healthcare decision-making could improve recommendation precision and personalization. Methods This retrospective study analyzed GPT travel vaccine recommendation accuracy against a gold standard from health professionals for 90 travelers visiting various countries. Sociodemographic data and vaccine recommendation outcomes were examined. Accuracy assessments were stratified by age, sex, country of travel, duration of travel, type of travel, and specific vaccines. Results Preliminary results showed an 77.43% overall accuracy across all vaccine recommendations. Specific vaccine accuracies varied, with 97.78% alignment for hepatitis A, 93.51% for typhoid fever and 89.36% for rabies. However, lower accuracies were observed for cholera (33.33%) and encephalitis (56.25%). Moderate accuracies were noted for yellow fever (75%), 74.07% for malaria prophylaxis, diphtheria and tetanus (63.33%), and dengue (57.58%). Stratified analyses are expected to provide more realistic results and highlight discrepancies in certain groups. Conclusions This pilot demonstrates GPTs can be a valuable tool for supporting international vaccination professionals, but they are still not a substitute for these professionals, achieving 77.43% overall accuracy. Recommendations include: a) Educate health professionals in the use of GPTs, b) Developing guidelines for ethical and accurate AI use in public health, c) Using AI to strengthen surveillance and response systems. Combining AI with traditional strategies aims to optimize international traveler health outcomes. Key messages • Using artificial intelligence can optimize and facilitate the task of clinical consultancy in traveler’s advice. • It is necessary to establish guidelines for AI use to ensure ethical and accurate applications.

Virtual clinics in oral surgery: an equitable service for all?

Introduction Teledentistry has become more prevalent in the provision of oral healthcare since the COVID-19 pandemic. Virtual consultation clinics were introduced at Birmingham Dental Hospital as an adjunct to face-to-face (F2F) consultation clinics. This service evaluation compares virtual and F2F consultation clinics in oral surgery, with particular focus on 'did not attend' (DNA) rates.Methodology Data were collected retrospectively from all clinics conducted within the oral surgery service in April 2021. Information collected included attendance, patient demographics and complications impeding the consultation, including technical difficulties. Patients' postcodes were used to generate deprivation deciles. All data were handled sensitively in line with the Caldicott principles.Results Binomial regression analysis showed that DNA rates were more likely to occur in virtual consultation clinics compared to F2F clinics (p <0.00). DNAs were less likely to occur at review appointments (p <0.00). Lower deprivation decile ratings were associated with higher rates of DNAs, independent of clinic type (eg review or new patient) or method of consultation (virtual versus F2F) (p <0.01).Conclusion While virtual clinics are advantageous for some patient demographics and have shown promising results in other studies, it is important that the delivery of these virtual services does not continue to marginalise vulnerable patient groups and enhance pre-existing oral health inequalities.

The Expanding Role of United States Healthcare Chaplains in Clinical Ethics.

Healthcare chaplains in the United States increasingly report being tasked by their organizations to participate in the formal work of clinical ethics, by serving on ethics committees, performing clinical ethics consultations, or leading clinical ethics programs. This mapping study documents that professionally-trained chaplains possess a number of skills and attributes that enhance their capability for this work; however, they often lack certain knowledge specific to the discipline of clinical ethics that is needed for roles they are being asked to perform. The professional associations of both chaplaincy and clinical ethics are encouraged to address this educational gap for the benefit of both disciplines.

12 Access to paediatric maltreatment services through a northern community hospital

Abstract Background Few studies have evaluated how paediatric maltreatment services based in community hospitals can provide access to care for populations who live far away from tertiary centres. The Violence Intervention Prevention Program (VIPP) and the Paediatric Abuse and Referral Evaluation (PARE) clinic based in a northern community hospital in Canada offer assessment for sexual and physical maltreatment. Objectives The aim of the study was to describe demographic and clinical characteristics of patients accessing VIPP and PARE services and to characterize the length of time required to access care. Design/Methods We conducted a retrospective chart review of patients, under 16 years of age, who attended PARE clinic for initial consultation between 2017-2019. Analyses were descriptive. This work was approved by the research ethics board at our hospital. There are no funding disclosures. Results Of 164 patients, 62.2% were female; 37.8% male. The mean age was 6.6 years, ranging from 1 month to 15.9 years. 54.3% of referrals were for suspected physical maltreatment, 44.4% for suspected sexual maltreatment and 1.2% for both. 87.5% of patients listed home addresses within the hospital’s city limits. The maximum distance travelled from home to access care was 171 km. 87.2% of patients presented through the emergency department; a minority presented through direct referral to outpatient services (11.5%) or through inpatient (1.2%). When called from the emergency department, on-call VIPP nurses responded within a mean of 32 minutes for initial assessment. These patients received a maltreatment assessment by a paediatrician through the PARE clinic a mean of 14.3 days later. If patients did not present through the emergency department, the mean wait time for a maltreatment assessment by a paediatrician was 16 days. 13.4% (22/164) required referral to other medical or multidisciplinary services. General paediatrics (11/22) was the most frequent referral, followed by community speech programs (5/22). A minority (3.0%) of cases required consultation with external maltreatment teams, where two cases were peer-reviewed with a tertiary care team, one with a paediatric maltreatment physician at another community hospital and two cases were reviewed with a paediatric tertiary care radiologist. Conclusion Our results suggest that community-based paediatric maltreatment services provide care for our regional northern population. There is timely on-call access to allied-health providers through the emergency department. All patients were able to be assessed locally and none were required to travel to a tertiary care hospital. Further study is needed to assess how our data compares to other community maltreatment programs.

Temporal trends and practice variation of paediatric diagnostic tests in primary care: retrospective analysis of 14 million tests

ObjectiveThe primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.Methods and analysisThis was a descriptive study of population-based data from Clinical Practice...

Time Motion Study of Tuberculosis Patients Attending a Hospital in an Indian State

Abstract Objectives: To analyse the time taken in availing various services by a patient of cardinal symptoms of Tuberculosis in TB Hospital, Bhopal, India and to determine the satisfaction of patients regarding care. Methods: This is a time–motion observational study of patients who came with symptoms of TB. A sample of 210 was calculated using Cochran’s formula. Results: Amongst the 210 patients studied, the majority were males, i.e. 123 (58.6%). A striking feature was found during this study that reports of sputum were given 2–5 days after collection. Conclusion: This busy hospital dedicated to providing comprehensive healthcare pertaining to TB had multiple patient queues, long clinical visits and short clinical encounters. Although the patients were satisfied with the clinical consultations from the doctors, they found difficulty in availing laboratory and X-ray services.

Dietary Health Communication and Conversation Analysis: A Scoping Review

ABSTRACT Globally, many people don’t eat a healthy diet despite policies and public health frameworks deployed to improve dietary status. Healthy diets can prevent, manage, and even reverse chronic disease, highlighting the importance of health professionals addressing healthy diets in clinical consultations. Conversation analysis (CA) is a method that can be used to understand dietary talk in these clinical consultations; however, it is unclear to what extent CA has been used for this purpose. Using PRISMA guidelines, a scoping review was conducted with the aim of identifying and summarizing research where CA was used to examine the dietary health conversations between health professionals and adults. A systematic search resulted in 4161 articles retrieved, with 13 studies meeting inclusion criteria. Included studies used CA to examine a variety of phases of dietary health encounters, including dietary assessment, advice-giving and resistance to this dietary advice, and dietary (lifestyle) behavior change negotiations, with n = 6 using audio or video recording, respectively. Studies were conducted in seven countries and across primary, secondary, and tertiary settings. We highlighted that dietary talk, irrespective of purpose (e.g., evaluation, assessment, or persuasion [e.g., behavior change]), is under-researched within the CA field. This is a need for further research using CA on dietary talk across a range of settings, conditions, populations, and talk purposes to understand how health professionals impact patient dietary behaviors. Such understanding has the potential to contribute to the improvement of dietary health communication approaches and patient outcomes.

The Decline of Medicare Reimbursement in Clinical Pathology

Abstract Introduction/Objective Access to clinical pathology services nationwide is threatened by the lack of an annual inflationary update for physician reimbursement from the Centers for Medicare &amp; Medicaid Services (CMS). Most recently, the 2024 Medicare Physician Fee Schedule (MPFS) implemented an overall 2.0% reduction in pathology reimbursement. The effects of recent inflationary trends on clinical pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for clinical pathology procedures. Methods/Case Report The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. A subset analysis was conducted to assess physician pathology clinical consultation services average annual and total percent change in reimbursement pre- and post- 2022 MPFS Update. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation- adjusted monetary data. Results (if a Case Study enter NA) Prior to adjusting for inflation, the average physician reimbursement decreased by 6.8% from 2004 to 2024 for included clinical pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 44.0% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for flow cytometry interpretation, 2-8 minutes at 69.5% ($114.44 to $34.95) followed by flow cytometry interpretation, 9-15 minutes at 57.8% ($142.77 to $60.25) and flow cytometry interpretation, &amp;gt;16 minutes at 56.6% ($188.05 to $81.55). The average CAGR was -2.86%. Prior to adjusting for inflation, the average physician reimbursement for clinical pathology consultation services pre-2022 decreased by 0.9%, and when adjusted for inflation, decreased by 30.0%. Post-2022 MPFS revision, the average physician reimbursement for clinical pathology consultation services decreased by 3.5%, and when adjusted for inflation, decreased by 12.2%. The average CAGR pre-2022 was -2.0% and post-2022 was -4.3%. Conclusion Medicare physician reimbursement for common clinical pathology procedures is decreasing at an untenable rate annually. It is critical that policymakers understand these trends to ensure continued access to quality clinical pathology care at healthcare institutions.

Red herrings and zebras and TB, oh my! Unexpected bone marrow presentation of Mycobacterium tuberculosis

Abstract Introduction/Objective Epithelioid granulomas are uncommon and non-specific findings in bone marrow samples, and should prompt additional testing for appropriate diagnosis and treatment, especially in the immunocompromised patient. The differential diagnosis for bone marrow granulomas includes infections, neoplasia, autoimmune disease, sarcoidosis, and drug/therapy reaction. Although bone marrow workup to delineate the cause of granulomas should include staining to rule out both infection and lymphoma, morphologic review is often inconclusive. Final diagnosis requires clinical consultation and additional testing. Methods/Case Report A 76-year-old male was admitted to the hospital from the emergency department for a level 2 trauma after being found on the ground ~3 hours after a fall. The patient reported a recent increasing frequency of falls with associated weakness, as well as an almost 30 lb weight loss over the last 3.5 months and low grade fevers over several weeks. His past medical history was significant for treatment for urothelial carcinoma with transurethral resection and BCG therapy, hypertension, coronary artery disease, and peripheral vascular disease. Imaging showed hepatosplenomgaly, suspicious for early cirrhosis, and mild peripancreatic lymphadenopathy. Initial laboratory abnormalities demonstrated mild anemia, low albumin, and mild increase in ALT, AST, and alkaline phosphotase. Initial Infectious Diseases workup was negative for causative etiology (blood cultures, tick-borne parasites, and respiratory pathogens). Patient symptoms did not improve and cytopenias worsened. A bone marrow biopsy showed multiple non-necrotizing epithelioid granulomas. Despite low clinical concern for infectious etiology, mycobacteria blood culture isolated Mycobacterium tuberculosis complex. Final results were available 112 days after specimen collection. Results (if a Case Study enter NA) NA Conclusion Although tuberculosis is commonly associated with granulomatous pathology, infection is very uncommon in North American patients who have not traveled and alternative diagnoses might initially be favored. A high suspicion for mycobacterial infections is essential for diagnosis even in low-incidence populations with no known exposure or risk factor(s).