Clinic Visit Research Articles

Mini-mental status examination phenotyping for Alzheimer’s disease patients using both structured and narrative electronic health record features

Abstract Objective This study aims to automate the prediction of Mini-Mental State Examination (MMSE) scores, a widely adopted standard for cognitive assessment in patients with Alzheimer’s disease, using natural language processing (NLP) and machine learning (ML) on structured and unstructured EHR data. Materials and Methods We extracted demographic data, diagnoses, medications, and unstructured clinical visit notes from the EHRs. We used Latent Dirichlet Allocation (LDA) for topic modeling and Term-Frequency Inverse Document Frequency (TF-IDF) for n-grams. In addition, we extracted meta-features such as age, ethnicity, and race. Model training and evaluation employed eXtreme Gradient Boosting (XGBoost), Stochastic Gradient Descent Regressor (SGDRegressor), and Multi-Layer Perceptron (MLP). Results We analyzed 1654 clinical visit notes collected between September 2019 and June 2023 for 1000 Alzheimer’s disease patients. The average MMSE score was 20, with patients averaging 76.4 years old, 54.7% female, and 54.7% identifying as White. The best-performing model (ie, lowest root mean squared error (RMSE)) is MLP, which achieved an RMSE of 5.53 on the validation set using n-grams, indicating superior prediction performance over other models and feature sets. The RMSE on the test set was 5.85. Discussion This study developed a ML method to predict MMSE scores from unstructured clinical notes, demonstrating the feasibility of utilizing NLP to support cognitive assessment. Future work should focus on refining the model and evaluating its clinical relevance across diverse settings. Conclusion We contributed a model for automating MMSE estimation using EHR features, potentially transforming cognitive assessment for Alzheimer’s patients and paving the way for more informed clinical decisions and cohort identification.

Pioneering sustainable treatment delivery in childhood leukemia through synchronous telemedicine—A pilot study

AbstractCancer care places a heavy economic burden on families and health systems, driven by high treatment costs, lengthy hospital stays, and the necessity for extensive travel to specialized facilities. To address this challenge, an integrated health care network (IHCN) was implemented for maintenance treatment in acute leukemia. The IHCN encompassed outpatient services provided by local physicians and synchronous telemedicine consultation with pediatric oncologists. This study included twenty‐two pediatric patients (eleven [50.0%] females; twenty [90.9%] with B‐ALL and two [9.1%] with AML). The IHCN was offered to all rural patients (n = 17) with a one‐way driving distance more than 30 km, while urban patients (n = 5) received regular cancer care. Throughout the study, rural patients had a total of 510 routine clinical visits, with 367 (72%) conducted through the IHCN. Physical examinations revealed similar frequency of new abnormal findings for urban and rural patients (22.4% vs. 17.8%; p = .31). Laboratory tests indicated no significant difference in the frequency of abnormal values for various parameters between both groups. Similarly, there was no discrepancy of drug modifications or interruption in maintenance therapy between the two settings (p = .85). Moreover, patients' health‐related quality of life remained within the normative range, and user satisfaction with the IHCN was notably high. The implementation of the IHCN resulted in savings of 70,158 km, 950 h of travel, and 12,277 kg CO2 emissions. This pilot study underscores the efficacy of a telemedicine‐based IHCN, ensuring safety, quality of care, cost reduction, and satisfaction for both families and health care providers in pediatric leukemia management.

Impact of the COVID-19 pandemic and lockdown measures on clinical visits and subjective symptoms in childhood allergic rhinitis induced by house dust mites in Shanghai

BackgroundEstablishing the interaction between aeroallergens and air pollution in children with house dust mite induced allergic rhinitis (HDM-AR) remains challenging, especially in urban areas. The coronavirus disease 2019 (COVID-19) pandemic and the subsequent lockdown measures provided a valuable opportunity.MethodsWe analyzed the clinical data of HDM-AR children between March and August in 2018–2020, and classified the children according to the type and the degree of HDM sensitization. The records of patients’ hospital visits, allergic rhinitis symptoms assessments, and air pollution measurements in Shanghai were used to assess the differences before (2018–2019) and during the pandemic (2020), as well as during lockdown (March-June) and unlockdown (July-August) period in 2020.ResultsThe study included 1570 HDM-AR children aged 2 to 8 years old, 815 (51.9%) were monosensitized to HDM (mono-HDM-AR), and 755 (48.1%) were polysensitized to HDM (poly-HDM-AR). There was a significant increase in the rate of clinical visits among children with HDM-AR during the COVID-19 pandemic compared to pre-pandemic (P < 0.001), particularly among older children aged 7–8 years (P = 0.01). During the unlockdown period, there was a notable decrease in clinical visits for children with poly-HDM-AR (P < 0.001). Children with high levels of HDM sensitization exhibited significant symptom improvement in unlockdown period (P < 0.001). Although the air pollutants concentration had improved during the study, there was no effect on the improvement of HDM-AR children as expected.ConclusionsThe COVID-19 pandemic and its associated lockdown measures provided a unique context to observe the dynamics of management in children with HDM-AR. The findings underscore the complexity of managing allergic conditions in pediatric populations, highlighting the influence of environmental and lifestyle changes on disease presentation and the need for tailored approaches to treatment during periods of societal disruption.

Modeling demand responsive service for the elderly healthcare activities considering temporal and spatial variations

ABSTRACT This paper develops a cost-effective demand-responsive transportation (DRT) model aimed at enhancing the accessibility and convenience of clinical visits for the elderly by optimizing two NP-hard problems. First, a set of pick-up stops is optimized based on potential stop locations, spatial and temporal demand, and acceptable walking distance. Next, vehicle routing and scheduling are optimized, considering vehicle capacity, users’ desired arrival times, and travel companions, to minimize total costs. An elite genetic algorithm (EGA) is developed to effectively search for the optimal solution. In the case study, demands are generated from a survey on elderly clinical visits and population census data in Xi’an. The proposed EGA is applied to different clustered demands classified by time interval to identify optimal solutions. Sensitivity analysis is conducted to explore the relationships between model parameters and decision variables for the studied DRT system.

Belimumab safety in adult and paediatric Chinese patients with systemic lupus erythematosus: A Phase 4, multicentre, observational study

Objective Although belimumab has been widely used in patients with systemic lupus erythematosus (SLE) globally, real-world safety data among Chinese patients are limited, particularly for children. This study assessed the safety and tolerability of belimumab in adult and paediatric patients with SLE in China in real-world clinical practice. Methods This Phase 4, multicentre, prospective, observational study enrolled patients prescribed intravenous belimumab by their physicians in tertiary hospitals, independent of a clinical study, during routine clinical visits between May 2021 and May 2022. Patients could have been receiving belimumab prior to enrolment. The primary objective was to describe the incidence of adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs) and AEs of special interest (AESIs) over the 24-week follow-up period. Data were collected at enrolment and approximately 4, 12 and 24 weeks post-enrolment, during routine clinical visits. AEs, ADRs and SAEs were collected as independent events. The safety population comprised patients who received ≥1 dose of belimumab and completed ≥1 follow-up visit. Results Overall, 417 patients were included in the analysis (safety population); 89.2% were female and mean (standard deviation) age was 35.5 (11.9) years. AEs were reported in 158 patients (37.9%) and were mostly mild (79.1%). The most common AEs were upper respiratory tract infections ( n = 19, 4.6%) and hypokalaemia ( n = 18, 4.3%; all mild). Among 22 patients (5.3%) with SAEs, four patients (1.0%) had drug-related SAEs (pneumonia, respiratory tract infection, gingivitis and decreased white blood cell and neutrophil count). ADRs were experienced by 25 patients (6.0%), most commonly urinary tract infections ( n = 5, 1.2%). There were no fatal SAEs. AESIs occurred in 14 patients (3.4%), including infections of interest ( n = 5, 1.2% all herpes zoster), serious selected psychiatric events ( n = 3, 0.7%) and infusion-related systemic and anaphylactic reactions ( n = 7, 1.7%). Of 14 paediatric patients enrolled, six experienced AEs, zero ADRs, two SAEs and one AESI. Conclusion Belimumab was generally well tolerated in adult and paediatric patients with SLE in this real-world setting in China, with no new safety signals identified. Future assessment of long-term belimumab safety in China beyond 24 weeks will extend this current body of evidence.

The impact of COVID-19 on routine child immunisation in South Africa

BackgroundThe COVID-19 pandemic disrupted immunisation programs worldwide, reversing gains that had brought vaccine-preventable diseases largely under control. This study explored the impact of COVID-19 on the uptake of routine child immunisation services in South Africa.MethodsWe conducted qualitative research using in-depth interviews with 51 purposively selected parents/caregivers of children below the age of five who missed or delayed one or more scheduled immunisation doses in 2020–2022 and with 12 healthcare providers who provided public immunisation services during the pandemic.ResultsDuring the pandemic lockdowns, most caregivers perceived the risk of their child being infected with COVID-19 during a clinic visit as more salient than the risk of missing immunisation doses. Caregivers reported minimal exposure to routine immunisation communication, as well as shortages of routine vaccines for children at public health facilities, healthcare workers experienced anxiety and burnout. There was a post-pandemic shift to more active decision-making about immunisation, which had previously been an almost automatic behaviour, leading some caregivers to delay vaccinating their children. There was also evidence of a “bad vaccine” mental model among some caregivers regarding COVID vaccinations, which could lead to doubts about the safety of routine childhood vaccinations.DiscussionThe shift from default to active decision-making highlights a risk that routine immunisation will backslide in future pandemics. Governments should build resilient health systems at all levels and communicate clearly about the benefits and availability of RIs and the safety of vaccinations in general, alongside supply-side interventions.ConclusionRoutine immunisation is widely accepted in South Africa, driven by generational norms and provider recommendations. During the COVID-19 pandemic, many caregivers faced the dilemma of balancing COVID-19 exposure risk with the risk of their child developing a deadly VPD, leading to missed RI visits. This shift to active decision-making highlights a future pandemic risk. Governments should build resilient health systems and focus on understanding and engaging procrastinating and doubtful caregivers. Clear communication about RI benefits and vaccine safety is crucial, as misinformation can lead to distrust in new vaccines.

Downstream healthcare use following breast cancer screening: a register-based cohort study

BackgroundFor evaluation of breast cancer screening and informed prioritisation, it is important to examine the downstream healthcare use associated to participation. The objective of this study is to determine the...

Patient-specific multifactorial mortality risk assessment using classification and regression tree analysis in the context of ambulatory blood pressure monitoring.

Ambulatory blood pressure monitoring is essential for understanding blood pressure patterns beyond clinical visits, aiding in risk assessment, treatment evaluation, and managing hypertension. This retrospective cohort study aimed to identify risk factors for all-cause mortality and major cardiovascular events in patients who underwent ambulatory blood pressure monitoring. Eligible participants aged 18 or older, with an estimated glomerular filtration rate (eGFR) > 60ml/min/1.73m2, who underwent ambulatory blood pressure monitoring for various reasons, were included in the study. Data were gathered through telephone interviews, electronic health records, and the national health record system. Descriptive analysis and classification and regression tree modeling were used to uncover significant risk factors related to all-cause mortality and cardiovascular events, and to assess the model's performance compared to traditional Cox survival analysis. The study included 1291 patients, primarily male (51.8%) with a mean age of 61.1 ± 15.2years. During a mean follow-up of 46.9months, 76 (5.9%) patients died of any cause, and 195 (15.1%) had a cardiovascular event. The highest survival rates were observed in patients with a diastolic blood pressure (BP) dipping percentage between -2% and 29%, nighttime systolic BP variability below 32mmHg, and age below 72. Conversely, smokers with a diastolic BP dipping percentage below -10% showed the lowest survival rates. The best cardiovascular outcomes were observed in patients with diastolic BP dipping above -11%, nighttime mean systolic BP < 144mmHg, no statin use, normotensive status, and daytime mean heart rate ≥ 60bpm. Conversely, the worst outcomes were seen in patients with diastolic BP dipping below -11% and a morning surge ≥ 14mmHg. In all-cause mortality and cardiovascular event analysis, the combined model demonstrated excellent calibration and predictive power, like the classification and regression tree model and traditional analysis. These findings highlight the potential of a combined model for assessing mortality and cardiovascular event risk in patients who have undergone ambulatory blood pressure monitoring.

Impact of Neighborhood Disadvantage on Preventive and Acute Care Utilization in Sickle Cell Disease.

Individuals with sickle cell disease (SCD) experience significant healthcare disparities; however, there is little known on the impact of psychosocial stressors and neighborhood disadvantage on preventive and acute care utilization in this population. A retrospective data collection was performed for all patients cared for at a comprehensive pediatric sickle cell center in the Midwest who had also completed the Psychosocial Assessment Tool (PAT), a validated caregiver-reported measurement of family psychosocial risk, from September 2021 through December 2022. Patient age, payor, primary language, frequency of acute and missed preventive care visits, as well as Area Deprivation Index (ADI) and Childhood Opportunity Index (COI) scores were collected for 256 patients. The average state ADI was 6.3 (±2.9), and the majority of patients were in the Very Low or Low COI categories. Total PAT score (p=0.003), state ADI (p<0.001), and state COI (p<0.001) were all significantly correlated with missed SCD clinic visits, with increased odds of a missed visit with increasing neighborhood disadvantage (OR 1.22, p<0.001). The odds of acute care were also increased in those with higher family psychosocial risk (OR 1.76, p<0.011), though this was not seen with ADI or COI, suggesting an additional effect of family stressors and resilience on acute care utilization. This highlights the importance of regular, universal social and psychological risk screening, as well as inclusion of psychosocial team members in SCD programs to identify and readily address risk factors that impact child outcomes in a minoritized chronic disease population.

Association of Questionnaire-Assessed Fall Risk With Uncontrolled Blood Pressure and Therapeutic Inertia Among Older Adults.

Therapeutic inertia (TI), or failure to escalate or initiate BP lowering medications when BP is uncontrolled, increases with advancing age and may in part be due to perceived fall risk. This study examined the association of a fall risk assessment, based on patient response to three questions administered by trained staff, with uncontrolled BP (≥140/90mmHg) during a clinic visit and with TI during clinic visits with uncontrolled BP among 13893 patients age ≥65 years corresponding to 41122 primary care visits. Separate generalized linear mixed effects models were used to examine the association of fall risk (low, moderate, and high) with uncontrolled BP and with TI at a clinic visit after adjustment for demographics, comorbidities, and total number of visits. Baseline mean age was 73.0 years (standard deviation [SD] 5.6), 43.3% were men and questionnaire-assessed fall risk severity was low in 73.6%, moderate in 14.3%, and high in 12.2%. Compared to low fall risk, the adjusted odds of uncontrolled BP during a clinic visit were 0.97 (95% CI: 0.89, 1.06) and 0.90 (95% CI: 0.82, 0.98) with moderate and high fall risk, respectively. In contrast, adjusted odds of TI during a clinic visit with BP ≥140/90mmHg was 1.16 (95% CI: 1.01, 1.34) and 1.30 (95% CI: 1.11, 1.52) with moderate and high fall risk, respectively, compared to low fall risk. These findings suggest that perceived fall risk severity may be one of several factors that influence hypertension management in older adults.

Recording of non-musculoskeletal manifestations, comorbidities, and safety outcomes in European spondyloarthritis registries: a survey

Abstract Objectives Real-world evidence is needed to inform treatment strategies for patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), who have non-musculoskeletal manifestations (NMM), various risk factors, and comorbidities. International collaboration is required to ensure statistical power and to enhance generalisability. The first step forward is identifying which data are currently being collected. Across 17 registries participating in the European Spondyloarthritis research collaboration, we aimed to map in a survey recording practices for NMMs, comorbidities, and safety outcomes in patients with PsA and axSpA. Methods Through a survey with 4,420 questionnaire items, we explored the recording practices of 58 pre-defined conditions (ie, NMMs, comorbidities, and safety outcomes) covering 10 disease areas. In all registries we mapped for each condition 1) whether it was recorded, 2) the recording procedure, and 3) the potential to identify it through linkage to other national registries. Results Conditions were generally recorded at entry into the registry and clinical follow-up visits using a pre-specified list or a coding system. Most registries recorded conditions within the following disease areas: NMMs (number of registries, n = 15–16), cardiovascular diseases (n = 10–14), gastrointestinal diseases (n = 12–13), infections (n = 10–13), and death (n = 14). Nordic countries had the potential for data linkage and generally had limited recording of conditions in their registry, while other countries had comprehensive recording practices. Conclusion A wide range of conditions were consistently recorded across the registries. The recording practices of many conditions and disease areas were comparable across the registries. Our findings support the potential for future collaborative research.

Diabetes Control and Clinical Outcomes among Children Attending a Regional Paediatric Diabetes Service in Australia

Australian children with diabetes commonly struggle to achieve optimal glycaemic control, with minimal improvement observed over the past decade. The scarcity of research in the rural and regional Australian context is concerning, given high incidence rates and prominent barriers to healthcare access in these areas. We conducted a retrospective audit of 60 children attending a regional Australian paediatric diabetes service between January 2020 and December 2023. The majority of patients had type 1 diabetes (n = 57, 95.0%); approximately equal numbers were managed with continuous subcutaneous insulin infusion (CSII) pumps vs. multiple daily injections (MDIs), whilst 88.3% (n = 53) also utilised continuous glucose monitoring (CGM). The mean age at last visit was 14.0 years (SD, 3.4), mean diabetes duration 5.8 years (SD, 4.6), and mean HbA1c level 8.1% (65.3 mmol/mol); only 36.8% achieved the national target of 7.5% (58 mmol/mol). Mean BMI-SDS was 0.8 (SD, 1.0); almost half (n = 27, 45.0%) were overweight or obese. Many patients had mental health conditions (31.7%), which were associated with higher hospitalisation rates (p = 0.007). The attendance rate was 83.2%, with a mean of 3.3 clinic visits per year (SD, 0.7); higher attendance rates were associated with increased CGM sensor usage (r = 0.395, p = 0.007 Overall, the diabetes service performed similarly to other clinics with regards to glycaemic control. Whilst achieving treatment targets and addressing comorbidities remains a challenge, the decent attendance and the high uptake of healthcare technologies is commendable. Further efforts are needed to improve diabetes management for this regional community.

High Preoperative Expectations may not Need to be Feared.

Retrospective. Evaluate correlations between preoperative expectations for pain improvement and 12-month functional outcomes and satisfaction following 1-2 level primary anterior cervical surgery. Limited data exists evaluating correlations between patients' preoperative expectations for pain relief and subsequent functional and satisfaction outcomes following primary anterior cervical surgery. Understanding correlations between expectations and outcomes may help identify patients most likely to benefit from surgery. Patients who underwent 1-2 level primary ACDF or CDA for degenerative disease between 2016-2021 were included. All patients had 12-month NDI data. Preoperative expectations for pain relief were collected at the initial clinic visit using 5-point Likert scales. Preoperative and 12-month postoperative satisfaction were recorded using 7-point Likert scales. Covariates including age, gender, procedure type, smoking status, opioid use, worker's compensation/litigation, BMI, and indication (radiculopathy versus myelopathy). Linear regression models were constructed to assess 12-month NDI change score versus pain relief expectations. Additional regression models assessed expectations versus achievement of MCID at 3- and 12-months and satisfaction at 12-months. 198 ACDF (56.1% female, median age 57) and 52 CDR patients (55.8% female, median age 51) were included. Regression models found no significant correlations between pain relief expectations and degree of NDI score improvement at the 12-month postoperative timepoint or MCID achievement at the 3- and 12-month postoperative timepoints. There was no association between preoperative expectations and 12-month satisfaction. However, greater preoperative dissatisfaction was significantly associated with greater 12-month improvement in NDI score. Preoperative pain relief expectations were not associated with functional outcomes or satisfaction following 1-2 level primary ACDF or CDR at 12-month follow-up. Patients' dissatisfaction with their preoperative spinal condition was significantly associated with greater 12-month NDI improvement. Assessing preoperative satisfaction may help identify those most likely to benefit from surgery.

Intraoral scanning for implant-supported complete-arch fixed dental prostheses (ISCFDPs): Four clinical reports.

Although there are difficulties with using intraoral scans for implant-supported complete-arch fixed dental prostheses (ISCFDPs), several commercially available systems have become helpful in simplifying the treatment process in the prosthetic phase. These systems help patients move from interim ISCFDPs to receiving definitive prostheses in just three clinical visits. This clinical report summarizes the indications, benefits, and limitations of the four systems. The information provided in this report about the digital prosthetic workflow of ISCFDPs aims to help clinicians make well-informed choices and improve treatment results. With digital technologies advancing, refining these tools and protocols, and validating research is crucial for continued evolution in the field.

The impact of conditional cash transfer (CCT) on health and education in a coastal community: A randomized control trial (RCT) and regression discontinuity design (RDD)

This study evaluates the impact of the Pantawid Pamilyang Pilipino Program (4Ps), a national conditional cash transfer (CCT) on the health and education of beneficiaries in the coastal community of Maangas, Presentacion, Camarines Sur. It compares households receiving 4Ps benefits to a control group of non-recipients with similar sociodemographic characteristics to establish counterfactuals. Using a Randomized Control Trial (RCT) approach, data were collected from 157 participants in each treatment and control group through structured questionnaires. Descriptive statistics were utilized to analyze the economic profiles of respondents, revealing diverse representations. Logistic regression models unveiled significant correlations between attendance, dropout rates, and various predictor variables, notably the 4Ps program and eligibility, location, household size, and perceptions. Regarding health outcomes, the analysis demonstrates the positive impact of 4Ps membership on reducing child mortality, improving child growth, and promoting healthcare-seeking behaviors. Factors such as clinic visits, health insurance, and health beliefs also significantly influence health outcomes. RDD underscores the effectiveness of the 4Ps program in poverty alleviation, with eligibility playing a key role in enhancing income outcomes among beneficiaries. Prioritizing access to healthcare services, reinforcing the importance of regular clinic visits, and optimizing child health outcomes are crucial steps towards sustainability of the program. Tailored interventions based on enrollment status and academic performance can help prevent student attrition. Providing aid to coastal communities and embedding livelihood support programs in 4Ps can break the cycle of poverty by integrating these initiatives into the current structure of the program.

Costs of Care in Relation to Alzheimer's Disease Severity in Sweden: A National Registry-Based Cohort Study.

The advancement of diagnostic and therapeutic interventions in early Alzheimer's disease (AD) has demanded the economic evaluation of such interventions. Resource utilization and cost estimates in early AD and, more specifically, the amyloid-positive population are still lacking. We aimed to provide cost estimates in AD in relation to disease severity and compare these with the control population. We also aimed to provide cost estimates for a subset of the AD population with both clinical diagnosis and amyloid-positive confirmation. This was a retrospective longitudinal analysis of resource utilization using data from national registries. A cohort from the national Swedish registry for cognitive/dementia disorders (SveDem) includes all clinically diagnosed AD between 2013 and 2020. The study population included 31,951 people with AD and 63,902 age- and sex-matched controls (1:2). The population was followed until death, the end of December 2020, or 2years from the last clinic visit. Direct medical and social costs were estimated from other national registries. Direct medical costs include costs for medications and inpatient and outpatient clinical visits. Direct social costs include costs for institutionalization, home care, short-term care, support for daytime activities, and housing support. Mean annual costs and 95% confidence intervals were obtained by bootstrapping, presented in 2021 Swedish Krona (SEK) (1 SEK=0.117 USD, 1 SEK=0.0985 EUR in 2021), and disaggregated by AD severity, cost component, sex, age group, and care setting. Mean annual costs for individuals with clinically diagnosed AD were SEK 99,906, SEK 290,972, SEK 479,524, and SEK 795,617 in mild cognitive impairment (MCI), mild, moderate, and severe AD. The mean annual costs for the population with both clinical diagnosis and amyloid-positive AD confirmation (N=5610) were SEK 57,625, SEK 179,153, SEK 333,095, and SEK 668,073 in MCI, mild, moderate, and severe AD, respectively. The mean annual costs were higher in institutionalized than non-institutionalized patients, females than males, and older than younger age groups. Inpatient and drug costs were similar in all AD severity stages, but outpatient costs decreased with AD severity. Costs for institutionalization, home care, support for daytime activities, and short-term care increased with AD severity, whereas the cost of housing support decreased with AD severity. This is the first study estimating annual costs in people with AD from MCI to severe AD, including those for the amyloid-positive population. The study provides cost estimates by AD severity, cost components, care settings, sex, and age groups, allowing health economic modelers to apply the costs based on different model structures and populations.

Early vestibular rehabilitation initiation is associated with faster recovery after sport related concussion

ObjectivesVestibular rehabilitation is a recommended treatment after sport related concussion (SRC), but the optimal timing is not fully understood. This research examined the association between the timing of vestibular rehabilitation initiation and recovery time in adolescent patients with SRC. DesignRetrospective cross-sectional. Methods112 patients with SRC were referred to vestibular rehabilitation at a specialty concussion clinic. Vestibular rehabilitation initiation was defined as days from date of injury to date of first vestibular rehabilitation assessment. Patients were dichotomized by vestibular rehabilitation initiation: EARLY (8–10 days) and LATE (>10 days). Recovery time was defined as days between injury and medical clearance from the clinic. Results60 (average age 15.22 ± 1.61 years; 51.7 % male) patients were in the EARLY group and 52 (average age 15.37 ± 1.31 years, 28.9 % male) patients were in the LATE group. There were more female patients in the LATE group (p = 0.01) and the LATE group had their first clinic visit later than the EARLY group (p < 0.02). The EARLY group had shorter recovery time (median 26, IQR [21, 32.5] days) compared to the LATE group (median 31, IQR [23.5, 52.5] days; p = 0.02). After controlling for confounding variables, the LATE group had recovery times that were 1.39 times as long as the EARLY group (p < 0.01). ConclusionsFor patients with vestibular issues after SRC, early vestibular rehabilitation initiation is associated with faster recovery time after SRC. The current study provides clarity on the optimal timing of vestibular rehabilitation after SRC.

Efficacy of Diagnostic In-Office Shoulder Ultrasound in the Surgical Treatment of Full-Thickness Rotator Cuff Tears.

Early surgical management of full-thickness traumatic rotator cuff tears (RCTs) may optimize functional outcomes, prioritizing timely diagnoses. Ultrasound and magnetic resonance imaging (MRI) are highly sensitive and specific modalities for RCT diagnosis, yet MRI remains the gold standard diagnostic tool despite increased costs and potential delays in care. Ultrasound can provide same-day diagnosis, thus possibly expediting care. The use of diagnostic shoulder ultrasound alone in the orthopaedic surgeon's office could increase the efficiency of diagnosis and care of traumatic full-thickness RCTs compared with MRI. Cohort study; Level of evidence, 3. A retrospective chart review of patients with full-thickness traumatic RCT diagnosed via ultrasound or MRI who subsequently underwent rotator cuff repair with 1 of 2 ultrasound-trained surgeons between January 1, 2014, and December 31, 2019, was performed. Inclusion criteria included patients ≥18 years old, documentation of a first-time traumatic event, and the patient's desire to have immediate surgical management. Revision surgeries, long-term shoulder instability, and nontraumatic injuries were excluded. Basic demographic data were collected, and the number of preoperative office visits and the timing from initial evaluation to diagnosis and surgery were calculated for the ultrasound and the MRI cohorts. A power analysis of 0.8 with an alpha of .05 required 38 patients per group. Overall, 133 patients were diagnosed via MRI compared with 76 via ultrasound. Besides body mass index, there were no significant differences in demographic variables or insurance status. Compared with the MRI cohort, patients in the ultrasound cohort received their diagnosis almost 2 weeks faster (P < .0001), were scheduled for surgery almost 3 weeks faster (P < .0001), and underwent surgery 2 weeks faster after initial evaluation (P < .0001) while requiring nearly half as many clinical visits (P < .0001). Regression analysis confirmed that ultrasound significantly reduced time to imaging, scheduling, and surgery after initial evaluation while requiring fewer clinical visits (P < .05). The study findings indicated that ultrasound was a time-saving alternative diagnostic modality for traumatic RCT compared with MRI without compromising standard of care. These results were achieved independent of patient insurance status, disability index, or other demographic variables.

Evaluating the Diagnostic Utility of the Flexion-Compression Test for Carpal Tunnel Syndrome

BackgroundWe sought to determine the diagnostic utility of the flexion-compression (F-C) test for carpal tunnel syndrome (CTS). Using electrodiagnostic testing as the gold standard, we hypothesized that the F-C test would be a better diagnostic test for CTS as compared to the wrist flexion (Phalen’s) or palmar compression (Durkan’s) tests alone. MethodsWe studied patients who presented with and without CTS symptoms, designated as study and control group patients, respectively. At the first clinic visit, all patients were evaluated using the CTS-6 score, and then the Phalen’s, Durkan’s, and F-C tests in a random order. Patients in the study group were then sent for electrodiagnostic testing. Results162 patients were included after power analysis, 81 each in the study and control groups. Among study group patients with electrodiagnostic evidence of CTS, the positive likelihood ratio (LR+) of the Phalen’s test (1.29) was higher than the Durkan’s (1.06) and F-C (0.95) tests, though less than the CTS-6 score (1.64). Performing any physical exam test in conjunction with the CTS-6 score was not more useful than the CTS-6 alone. As expected, all three physical exam maneuvers were more likely to be positive among study patients compared to control patients. ConclusionsNone of the physical exam maneuvers were highly predictive of electrophysiologically-positive CTS. The CTS-6 score alone better predicts electrodiagnostic evidence of CTS than physical exam, though it only very slightly increases the post-test probability of disease. Formal electrodiagnostic testing remains important in diagnosing CTS when compared to physical exam maneuvers and CTS-6.

Comparing costs associated with management of antibiotic-recalcitrant recurrent urinary tract infections for one year pre- and post-electrofulguration.

To quantify and compare recurrent urinary tract infection costs between 1 year before and 1 year after electrofulguration. Following IRB approval, a well-characterized cohort of non-neurogenic women with >3 symptomatic urinary tract infections(UTIs)/year, a negative upper and lower urinary tract evaluation, and inflammatory bladder lesions (cystitis) on office cystoscopy who underwent fulguration of these lesions was analyzed. Cost of visits, imaging, labs, and medications were summed for 1-year pre- and post-fulguration using the Medicare Physician Fee Schedule, local pharmacy pricing, and institutional expenses. Before fulguration, all patients underwent clinic visit, noninvasive flow study, and flexible cystoscopy, and post-fulguration, 6-week follow-up visit and 6-month cystoscopy. Ninety-threewomen met study criteria (mean age 64), with 100% 1-year follow-up. Before fulguration, 73% of patients used daily antibiotic suppression, 6% self-start antibiotics, and 5% postcoital prophylaxis. Some also used vaginal estrogens (17%), urinary analgesics (13%), and cranberry or d-mannose supplements (7%). At 1 year post-fulguration, 82% had 0-1 infections and no cystoscopy evidence of cystitis, while 14% required additional fulguration for new cystitis sites and recurrent infections. Patients had on average 0.7 infections in the 1-year post-fulguration, which was significantly lower than pre-fulguration (p < 0.05). Mean 1-year pre-fulguration cost was $1328 (median $1071, range $291-$5564). Mean 1-year post-fulguration cost was $617 (median $467, range $275-$4580). On average, post-fulguration costs were $710 lower than pre-EF (p < 0.05). For women with antibiotic-refractory recurrent urinary tract infections and cystoscopy evidence of cystitis, fulguration was associated with a significant reduction in UTI-related costs in the 1-year post-fulguration.