Daily Consultations Research Articles

The Effect of Season and Weather on Orthopaedic Trauma: Consult Volume Is Significantly Correlated with Daily Weather

Introduction On-call orthopedic clinicians have long speculated that daily consult volume is closely correlated with weather. While prior studies have demonstrated a relationship between weather and certain fracture types, the effect of weather on total orthopaedic consult volume has not yet been examined. The aim of this study was to investigate this relationship. Methods We retrospectively reviewed orthopaedic consult data from 405 consecutive days at an urban, level one trauma center. The number, mechanism of injury, and type of consult were collected, along with daily weather data (temperature, wind, and precipitation). Statistical analysis was then performed to determine the relationship between weather and orthopaedic trauma consults. Results A total of 4543 consults were received during the study period. There was a significant difference in total number of consults between months of the year (p<0.001). A post hoc analysis revealed that this was due to increased volume in the summer months relative to the winter months (i.e., August 13.7 consults/day; January 9.3 consults/day). Average daily temperature and consult volume were also positively correlated (p<0.001, r= 0.30). While there was no significant association between precipitation and total consult volume, when there was over 0.25 inches of rain, there were less penetrating trauma (p=0.034) and motorcycle collision consults (p=0.013). Conclusion Weather parameters, specifically average temperature and precipitation, were found to be associated with daily orthopedic consult type and volume. Additionally, consult volume varies significantly between months of the year. Because trauma centers are often resource scarce, this is an important relationship to understand for proper resource allocation.

Surgical-Based Classification for Microtia.

The known classifications for microtia have been cumbersome and difficult to apply in daily consultation. The lack of a progressive surgical behavior according to each degree of affection also contributes to confusion and in a lower success rate in clinical application. The authors propose a progressive surgical classification that takes into consideration the principal anatomical defect and the corresponding correction with modern techniques, having eliminated from previous classifications, those elements that are now considered deformations of the ear, capable of conservative treatment in early stages of life.

Common questions about allergy. Practical approach to diagnosis and management in primary care

Allergic diseases are disorders with different clinical manifestations that are present in 20 to 40% of the general population. Since they share a common mechanism, several processes of this type often occur in the same individual, thus generating numerous symptoms and important economic costs for patients and their families. Currently, medical management of these diseases is focused on three main aspects: to identify and avoid the causative agent, acute symptoms' control through pharmacological treatment and generation of tolerance with immunomodulation or desensitization. However, owing to the different underlying mechanisms, different diagnostic approaches are necessary, which can become a real challenge for the treating physician. In addition, sometimes patients undergo different restrictions and unnecessary treatments, thus limiting their daily activities, modifying their diet and directly affecting their quality of life. A review is made, aimed at answering different concerns arising from daily patient consultation.

First aid stations and patient demand in tsunami-affected areas of Iwate Prefecture following the Great East Japan Earthquake

We report the number of first aid stations established in tsunami-affected areas following the Great East Japan Earthquake of 2011 and the number of patient consultations, and discuss the demand and supply of medical services in a tsunami disaster. A total of 76,952 medical records from 188 first aid stations in coastal areas of Iwate Prefecture were analyzed and the numbers of daily consultations were calculated. There were only 25 consultations on the day of the disaster, the number rapidly increased to 1603 consultations seven days after the disaster, and reached a peak of 2090 consultations twelve days after the disaster. Request of prescribed drugs for daily use accounted for approximately 30–50% of all consultations during first four weeks after the disaster. We noted the number of first aid stations in each municipality and analyzed the number of consultations during the first four weeks after the disaster, calculated per 1000 residents in each municipality. In municipalities where hospitals and clinics were damaged, the number of first aid stations per 1000 residents and number of consultations during the first four weeks correlated well with the proportion of the resident population in the flooding area. The municipalities with extensive damage needed three first aid stations and 700 consultations per 1000 flooding population during the first four weeks after the disaster.

Which Benefits and Harms of Using Fenugreek as a Galactogogue Need to Be Discussed during Clinical Consultations? A Delphi Study among Breastfeeding Women, Gynecologists, Pediatricians, Family Physicians, Lactation Consultants, and Pharmacists.

Background Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations. Methods A two-iterative round Delphi technique was used in two separate panels of breastfeeding women (n = 65) and healthcare providers (n = 56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek. Results About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations. Conclusion Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended.

Modification of Calgary-Cambridge Observation Guide, a more simplified and practical communication guide for daily consultation practice

Latar belakang: The Calgary-Cambridge Observation Guides (CCOG) adalah panduan yang telah digunakan di banyak negara untuk menilai keterampilan Komunikasi Dokter-Pasien. Panduan terdiri dari 56 poin yang terbagi dalam enam kategori dan menggambarkan proses konsultasi rutin, ditambah 15 poin opsional dalam memberikan penjelasan dan perencanaan. Karena panduan ini terdiri atas poin yang jumlahnya cukup banyak, sangat tidak praktis untuk menggunakannya dalam praktik konsultasi sehari-hari. Oleh karena itu, versi yang lebih sederhana dan praktis akan memberikan manfaat yang lebih besar. Metode: Tujuh orang ahli dari berbagai latar belakang kepakaran klinis dan komunikasi dokter pasien diminta mengevaluasi dan menganalisis 56 poin CCOG berdasarkan tingkat kepentingan dalam praktik sehari-hari. Dua putaran Delphy digunakan dalam penelitian ini, putaran pertama untuk mengevaluasi tingkat kepentingan, dan putaran kedua untuk mengevaluasi poin-poin yang memiliki kesamaan makna sehingga dapat digabungkan. Hasil dari dua putaran itu kemudian disirkulasikan kembali kepada semua anggota tim ahli untuk mendapatkan konfirmasi versi modifikasi akhir dari CCOG tersebut. Hasil: Versi modifikasi terakhir dari CCOG yang terdiri dari 35 titik telah terbentuk. Langkah pertama proses konsultasi yaitu Memulai sesi terdiri dari 5 poin (awalnya 7 poin). Langkah Mengumpulkan Informasi terdiri dari 5 poin (awalnya 11 poin), Menyediakan Struktur 3 poin (awalnya 4 poin), Membangun Hubungan 7 poin (awalnya 10 poin), Penjelasan dan Perencanaan 11 poin (awalnya 20 poin), dan Menutup Sesi terdiri dari 4 poin. Versi CCOG yang dimodifikasi tetap komprehensif, namun lebih praktis untuk latihan sehari-hari. Kesimpulan: Modifikasi versi CCOG dapat digunakan sebagai panduan praktis sederhana untuk menilai Komunikasi Pasien Dokter dalam praktik konsultasi sehari-hari. Kata Kunci: The Calgary-Cambridge Observation Guide, Komunikasi Dokter Pasien, Modifikasi Abstract Background: The Calgary-Cambridge Observation Guides (CCOG) is a guide that is widely used to assess Doctor-Patient Communication. The guide consists of 56 points divided into 6 categories that describe a routine consultation process, plus 15 optional points in giving explanation and planning. Due to its quite numerous points, it is quite impractical to use the guide in daily consultation practice. Therefore, a more simplified and more practical version would be favourable. Method: Seven experts from different background evaluated and analyzed the 56 points of CCOG based on the level of importance in daily practice. Two rounds of Delphy were used in the study, the first round to evaluate level of importance, and the second to obtain the possibilities to join items that may have similar meaning. The result of the two rounds was then recirculated to all members of the team for confirmation of the final modified version of CCOG. Result: A final modified version of CCOG consisting of 35 points was formed. The first step of a consultation process, Initiating the session consists of 5 points (originally 7 points). Gathering information step consists of 5 points (originally 11 points), Providing structure of 3 points (originally 4 points), Building relationship of 7 points (originally 10 points), Explanation and Planning of 11 points (originally 20 points), and Closing the Session consisting of 4 points. The modified CCOG version is still comprehensive, yet more practical for daily practice. Conclusion: Modified version of CCOG can be used as a simple, practical guide to assess Doctor Patient Communication in daily consultation practice. Keywords: The Calgary-Cambridge Observation Guide, Doctor Patient Communication, Modification

The ALMANACH Project: Preliminary results and potentiality from Afghanistan

IntroductionALMANACH (ALgorithms for the MANagement of Acute CHildhood illnesses) is an electronic version of IMCI (Integrated Management of Childhood Illness) running on tablets. ALMANACH enhances its concept, it integrates well into health staff's daily consultation work and facilitates diagnosis and treatment. ALMANACH informs when to refer a child or to perform a rapid diagnostic test (RDT), recommends the right treatment dosage and synchronizes collected data real time with a Health Management Information System (DHIS2) for epidemiological evaluation and decision making. ObjectivesSince May 2016, ALMANACH is under investigational deployment in three primary health care facilities in Afghanistan with the goal to improve the quality of care provided to children between 2 months and 5 years old. MethodsIMCI's algorithms were updated in considering latest scientific publications, national guidelines, innovations in RDTs, the target population's epidemiological profile and the local resources available. Before the implementation of the project, a direct observation of 599 consultations was carried out to assess the daily performance at three selected health facilities in Kabul. ResultsThe baseline survey showed that nutritional screening, vitamin A supplementation and deworming were not systematically performed: few patients were diagnosed for malnutrition (1.8%), received vitamin A (2.7%) or deworming (7.5%). Physical examination was appropriate only for 23.8% of the diagnoses of respiratory or gastrointestinal diseases, ear infection and sore throat. Respiratory rate was checked only in 33.5% of the children with fever and cough, dehydration status was assessed in only 16.5% of the diarrhoea cases. Forty-seven percent of patients received incorrect treatment. Sixty-four percent of the children, before the introduction of ALMANACH, received at least one antibiotic, although for 87.1% antibiotic therapy was unnecessary.The review of 8′047 paediatric consultations between May 2016 and September 2017 showed that with ALMANACH, malnutrition detection, deworming and Vitamin A supplementation increased respectively to 4.4%, 50.2% and 27.5%. Antibiotic prescription decreased to 21.83% and all children were examined and treated in compliance with the protocols. Conclusion: A survey will be conducted one year after the implementation to validate these initial promising results. If the efficacy of the approach is confirmed, ALMANACH could establish as a powerful innovation for primary health care.

Estimating primary care attendance rates for fever in infants after meningococcal B vaccination in England using national syndromic surveillance data

BackgroundIn September 2015, the United Kingdom became the first country to introduce the multicomponent group B meningococcal vaccine (4CMenB) into a national infant immunisation programme. In early clinical trials 51–61% of infants developed a fever when 4CMenB was administered with other routine vaccines. Whilst administration of prophylactic paracetamol is advised, up to 3% of parents may seek medical advice for fever following vaccination. We used research-level general practitioner consultations to identify any increase in attendances for all-cause fever in vaccine-eligible infants following 4CMenB introduction in England. MethodsConsultations for infant all-cause fever in the year following the vaccine introduction were identified from The Phoenix Partnership (TPP) ResearchOne general practice database using Read (CTV3) codes. Average daily consultation rates and incidence rate ratios (IRRs) were calculated for vaccine-eligible age groups and compared to the two years preceding vaccine introduction. The difference between pre- and post-vaccine all-cause fever consultations was estimated. ResultsAll-cause fever consultations in vaccine-eligible 7–10 week olds were 1.6-fold higher (IRR, 1.58; 95% CI, 1.22–2.05) compared to the two previous years and 1.5-fold higher (IRR 1.47; 95% CI, 1.17–1.86) in 15–18 week-olds. There were no significant differences in 0–6 or 11–14 week-olds. Applying the difference between pre- and post-vaccine consultation rates to the 4CMenB vaccine-eligible age groups across England estimated 1825 additional fever consultations in the year following 4CMenB introduction. ConclusionsWe found a small but significant difference in all-cause fever consultation rates in vaccine-eligible infants who would have received 4CMenB with other vaccines.

The Pediatric Heart Failure Workforce: An International, Multicenter Survey.

Our objective was to understand the scope of pediatric heart failure (HF) and the current staffing environment of HF programs. An online survey was distributed to members of the Pediatric Heart Transplant Study and the Pediatric Council of the International Society for Heart and Lung Transplantation. All participants received the primary 23-question survey. Additionally, HF program directors received a 32-question supplemental survey. Of 235 invitations sent, there were 69 (29%) primary surveys and 34 program director surveys completed (24 U.S. programs, 9 outside non-U.S., and one non-specified location). A formal HF program was reported by 88% of directors. There were 150 [IQR 50-200] outpatients/institution and 40% [25-50] of patients had congenital heart disease. Inpatient HF census was 3 [2-4] patients. Most programs (70%) used a consulting service model to provide HF specialty care, while only 10 (30%) utilized an inpatient HF service. Inpatient HF service programs had a higher daily inpatient census versus consult service model programs (4 [3-7] vs. 2 [1-4], respectively; p=0.022) and had a higher number of full-time equivalents dedicated to HF (5.5 [2-7] vs. 2.5 [1-4], respectively; p=0.024). Only 47% of programs report a general fellowship rotation devoted to HF. Advanced practice providers (APP) were utilized in 15 programs, nurse coordinators in 2, and both in 3. Most HF programs are formalized, utilize APP, and have inadequate HF staffing to utilize a separate inpatient HF service. Exposure of general pediatric cardiology fellows to HF care is variable between institutions.

Association between air pollution and emergency consultations for respiratory diseases

Background: Air pollution has a direct influence on health. Aim: To determine the association between particulate matter and contaminant gas concentrations in the environment with the number of consultations for respiratory diseases in emergency rooms in Metropolitan Santiago, Chile. Material and Methods: During five years, the daily number emergency consultations for respiratory diseases and the daily concentrations of particulate matter and contaminant gases in a community of Santiago, were recorded. The degree of change of these variables during summer and winter was determined. Their correlation coefficients with a 0 to 100 days gap, were calculated. Results: During winter, there was a higher number of consultations and higher pollution levels, except for O3 , which increased in summer. There were positive correlations between the concentrations of different pollutants (mainly 2.5 and 10 μm particulate matter, CO and NO2 ). There was a negative association between consultations for respiratory diseases and O3 concentrations, an almost negligible association with SO2 and variable positive and significant associations with the concentration of other pollutants, with variations according to the time gap. Conclusions: Pollution and respiratory diseases increase during winter. There are variable associations between pollutant concentrations and the number of consultations for respiratory diseases

Outcomes of telemedicine intervention in a regional intensive care unit: a before and after study.

Telemedicine consultations in remote intensive care units (ICUs) overseas were found to be effective in reducing mortality and hospital length of stay (LOS). In Australia, there were anecdotal reports of these clinical outcomes. This retrospective before and after study assessed the improvement in patient outcomes with the implementation of a telemedicine program in a regional high dependency unit. Daily virtual consultations were conducted between the rural facility and the intensivists at the regional centre. A total of 525 patients received intensive care support between 2010 and 2015. Hospital and High Dependency Unit mortality showed no evidence of significant differences between the telemedicine group and the baseline (relative risk 1.02, 95% confidence interval [CI] 0.99-1.06, P=0.25 and relative risk 1.00, 95% CI 0.98-1.03, P=0.67 respectively). The hospital LOS was lower in the baseline group by 1.5 days. There was no significant difference in High Dependency Unit LOS. To adjust for the covariates in LOS, log linear regression analysis was performed. The telemedicine intervention, Acute Physiology and Chronic Health Evaluation II scores and inter-hospital transfers were found to contribute significantly to hospital LOS. The most important result of the study was that the proportion of inter-hospital transfers was lower in the telemedicine group (relative risk 0.88, 95% CI 0.80-0.98, P=0.03) compared to baseline. This means that critically ill patients in our regional centre can continue to receive specialist care remotely through tele-ICU consultations thus avoiding the need for patient transport. However, further study is needed to establish the benefits and risks of telemedicine intervention in ICUs in Australia.

Integrated care pathway for rectal cancer treatment: health care resource utilization, costs, and outcomes.

Managed Flow C20 (MFC20) is an integrated care pathway (ICP) for rectal cancer implemented at a public teaching hospital. This study aims to quantify resource utilization and estimate direct costs and outcomes associated with the use of this ICP. We evaluated consecutive rectal cancer patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery, comparing the period before the ICP implementation (Pre-MFC20 group) and after (MFC20 group). We assessed times between treatment steps and quantified the resources utilized, as well as their costs. There were 112 patients in the Pre-MFC20 group and 218 in the MFC20 group. The mean treatment intervals were significantly shorter in the MFC20 group - from the first medical consultation to nCRT (48.3 vs. 87.5 days; P < 0.001); and from nCRT to surgery (14.8 vs. 23.0 weeks; P < 0.001) - as was the mean total treatment time (192.0 vs. 290.2 days; P < 0.001). Oncology consultations, computed tomography, MRI, and radiotherapy sessions were utilized more frequently in the Pre-MFC20 group (P < 0.001). The median per-patient cost was US$11 180.92 in the Pre-MFC20 group, compared with US$10 412.88 in the MFC20 group (P = 0.125). Daily hospital charges and consultations were the major determinants of the total cost of the treatment. There was no statistical difference in overall survival in the time periods examined. Implementation of a rectal cancer ICP reduced all treatment intervals and promoted rational utilization of oncology consultations and imaging, without increment in per-patient costs or detrimental effects in overall survival.

Infant fever trends following the launch of the meningococcal B vaccine in the UK

ObjectiveTo use syndromic surveillance data to assess whether there hasbeen an increase in GP fever consultations since the inclusion of themeningococcal B (MenB) vaccine in the UK vaccination schedule.IntroductionFrom 1 September 2015, babies in the United Kingdom (UK)born on/after 1 July 2015 became eligible to receive the MenBvaccine, given at 2 and 4 months of age, with a booster at 12 months.1Early trials found a high prevalence of fever (over 38°C) in babiesgiven the vaccine with other routine vaccines at 2 and 4 months.We used syndromic surveillance2data to assess whether there hadbeen increased family doctor (general practitioner (GP)) consultationsfor fever in young infants following the introduction of the vaccine.MethodsGP consultations for fever in infants aged under 1 year wereextracted from The Phoenix Partnership (TPP) ResearchOne database(400 GP surgeries in England).3Data were stratified by week ofage over the period 1 September 2015 to 30 November 2015 and1 December 2015 to 29 February 2016. Fever consultation rates(per 100,000 registered practice population in the database) werecompared to the same 3 month periods of the previous 5 years(2010-14) using incident rate ratios (IRR). Pre- and post-vaccinationconsultation rates were applied to the England 0-26 week populationto estimate excess fever consultations.ResultsBetween 1 September and 30 November 2015 the average dailyfever consultation rate for infants aged 0-26 weeks was 4.72/100,000;the incident rate ratio was 1.46 (95% CI, 1.09-1.92). In the 7-10 weekage group the average daily fever consultation rate was 7.79/100,000.The incidence rate was 2.68 times higher than in previous years(95% CI, 1.42-4.94).Between 1 December 2015 and 29 February 2016 the averagedaily consultation rate for infants aged 0-26 weeks was 6.19/100,000.The incidence rate was 1.49 times higher than in the same 3 monthperiod of previous years (95% CI, 1.16-1.90). In infants aged7-10 weeks the average daily consultation rate was 8.44/100,000and the incidence rate was 1.83 times higher than previous years(95% CI 1.03-3.16).Between 1 September 2015 and 29 February 2016 there werean estimated additional 959 fever consultations for infants aged0-26 weeks to English family doctors.ConclusionsWe have demonstrated an innovative use of syndromic surveillanceto quickly and easily assess the impact on healthcare seekingbehaviour for infants with fever following the introduction of a newvaccination into the routine vaccination programme in England. Ourstudy provides reassurance that in infants aged 0-26 weeks therewas no marked increase in consultations following the introductionof the new MenB vaccination. However, in some age groups below0-26 weeks there was an increase in healthcare seeking behaviour forfever, in particular, the 7-10 week age group which includes infantsaged 8 weeks receiving their first vaccination. Other age groups alsodemonstrated increased fever consultations during these two periods,albeit at less significant levels. We will analyse data for the full yearfrom 1 September 2015 to further explore these findings, investigatepotential confounders and assess trends since vaccine introduction.

Interactive effects of specific fine particulate matter compositions and airborne pollen on frequency of clinic visits for pollinosis in Fukuoka, Japan

BackgroundPrevious studies have revealed the interactive effects of airborne pollen and particulate matter on the daily consultations for pollinosis, but it is uncertain which compositions are responsible. This study aimed to investigate the interactive effects of specific PM2.5 compositions and airborne pollen on the daily number of clinic visits for pollinosis in Fukuoka. MethodsWe obtained daily data on pollen concentrations, PM2.5 compositions, PM2.5 mass, gaseous pollutants (SO2, NO2, CO, and O3), and weather variables monitored in Fukuoka between February and April, 2002–2012. In total, 73,995 clinic visits for pollinosis were made at 10 clinics in Fukuoka Prefecture during the study period. A time-stratified case-crossover design was applied to examine the interactive effects. The concentrations of PM2.5 and its compositions were stratified into low (<15th percentile), moderate (15th–85th percentile), and high (>85th percentile) levels, and the association between airborne pollen and daily clinic visits for pollinosis was analyzed within each level. ResultsWe found a significant interaction between specific PM2.5 compositions and airborne pollen. Specifically, the odds ratio of daily clinic visits for pollinosis per interquartile increase in pollen concentration (39.8 grains/cm2) at the average cumulative lag of 0 and 2 days during high levels of non-sea-salt Ca2+ was 1.446 (95% CI: 1.323–1.581), compared to 1.075 (95% CI: 1.067–1.083) when only moderate levels were observed. This result remained significant when other air pollutants were incorporated into the model and was fairly persistent even when different percentile cut-off points were used. A similar interaction was found when we stratified the data according to non-sea-salt SO42- levels. This finding differed from estimates made according to PM2.5 and NO3- levels, which predicted that the effects of pollen were strongest in the lower levels. ConclusionsAssociations between airborne pollen and daily clinic visits for pollinosis could be enhanced by high levels of specific PM2.5 compositions, especially non-sea-salt Ca2+.

Association of Asian Dust with daily medical consultations for pollinosis in Fukuoka City, Japan

BackgroundThe objective is to examine the association between AD and the daily number of medical consultations for pollinosis in Fukuoka City.MethodsWe analyzed 65,488 daily medical consultations for pollinosis from 4 clinics in Fukuoka City from February to April, 1989–2012. Time-series analyses were performed to estimate the clinic-specific relative risk (RR) of clinical pollinosis associated with AD, adjusting for airborne pollen, suspended particulate matter (SPM), meteorological and temporal factors. Delayed effects were considered. The association with SPM was also examined given its relationship with AD. The clinic-specific RRs were combined using meta-analytic technique.ResultsAD on the same day (lag 0) and the previous 3 to 5 days (lags 3, 4, and 5) was positively associated with the risk of medical consultations for pollinosis. Clinic visits were 21.5% (95% confidence interval 3.1% – 43.1%) higher when there was an AD event (across lags 0–5). The association with SPM showed comparable lag structure, but with smaller effect estimates. When stratified by the occurrence of AD, the estimated risk increases associated with SPM did not differ between the AD-affected and AD-free days.ConclusionAD is associated with an increased risk of medical consultations for pollinosis in spring. More research is needed to elucidate the roles of air particles with different sizes.

Impact of a Consult Cap for a Busy Inpatient Palliative Care Program (S773)

•Describe implementation of an inpatient consult cap at a large academic hospital.•Examine the impact of implementing a daily consult cap on a palliative care program. The ability of many hospital-based palliative care programs to provide high-quality care in a sustainable fashion is now paradoxically threatened by their own success. Approximately 10% of such programs have responded by instituting caps on consults, but the effects are unknown. We identified all palliative care inpatient consults requested from July 1, 2014 to April 30, 2016 at a large academic hospital. We describe the implementation of a hospital-wide daily cap on new consults on May 1, 2015, and compare the volume, characteristics, and timing of consults in the year before and year after the cap. The hospital-wide cap on new palliative care consults was typically set at 8 per day and varied based on available staffing and census. Consults requested after the cap were prioritized the following day. Mean monthly consult requests increased from 157.7 (range 126-196) in the year before to 173.7 (range 155-209) in the year after the cap (p<0.001), while the proportion actually seen decreased from 96.4% to 88.6% (p<0.001). There was no difference in mean pre-consult length of stay (8.4 days [SD 14.8] vs. 8.6 days [SD 14.3], p=0.75), the proportion of patients transitioned from aggressive to comfort care (38% vs. 35%, p=0.08), or the number of patients discharged to hospice (287 (25.4%) vs. 263 (24.4%), p=0.59). Following the cap, reduced proportions of consults originated from the Oncology and ICU services, and an increased proportion from General Medicine, but not all changes were statistically significant. Implementation of a daily cap on new palliative care consults did not reduce consultative demand, increase the time to consultation, or change the rates of hospice referrals or transitions in goals of care.

Personalized Preventive Plan in General Medicine

Background: In recent years, prevention has become increasingly important in General Medicine (GM) and has become the focus of several debates worldwide. The evolution of the Tunisian society urges to seek a preventive approach then a Specific Preventive Consultation (SPC) became a necessity. Objective: We aimed at determining the output of a SPC within a consultation of GM. Method: A descriptive study was carried out for 9 months (from November 2016 to July 2017) in a primary care at Monastir governorate. A SPC was incorporated into the daily care consultations. An appropriate questionnaire, highlighting cardiovascular, carcinogenic and depressive risk factors, was sent to 313 consultants who agreed and adapted actions have been proposed to them. We have analyzed follow up results for screened participants according to personalized preventive plan (PPP). Results: For 313 participants, 48 (15%) have high cardio vascular risk (HCVR). Obesity, physical inactivity, smoking and alcohol consumption were notified respectively among 30.5%, 19%, 19% and 7% of our population. Familial ATCD of breast cancer was present in 2.2%, anxiety in 32% and depression in 23% of our patients. All screened participants provided with a personalized prevention plan (PPP). Therapeutic education was performed for 140 patients; awareness to a tobacco free environment for 155 and 71 mammography was prescribed for women at risk from which one returned with cancer. Conclusion: SPC has improved the knowledge and practices of patients. It also identified several risk factors and especially breast cancer at an early stage. We concluded that Personalized Preventive Plan can be performed in GM to improve and promote health.

Modification of Calgary-Cambridge Observation Guide, a More Simplified and Practical Guide for Daily Consultation Practice

Background: The Calgary-Cambridge Observation Guides (CCOG) is a guide that is widely used to assess Doctor-Patient Communication. The guide consists of 56 points divided into 6 categories that describe a routine consultation process, plus 15 optional points in giving explanation and planning. Due to its quite numerous points, it is quite impractical to use the guide in daily consultation practice. Therefore, a more simplified and more practical version would be favourable. Method: Six experts from different background evaluated and analysed the 56 points of CCOG based on the level of importance in daily practice. Two rounds of Delphy were used. The result of the two rounds was then recirculated to obtain confirmation of the final modified version of CCOG. Result and Discussion: A final modified version of CCOG consisting of 35 points was formed. The first step of a consultation process, Initiating the session consists of 5 points (originally 7 points). Gathering information step consists of 5 points (originally 11 points), Providing structure of 3 points (originally 4 points), Building relationship of 7 points (originally 10 points), Explanation and Planning of 11 points (originally 20 points), and Closing the Session consisting of 4 points. The modified CCOG version is still comprehensive, yet more practical for daily practice. Conclusion: Modified version of CCOG can be used as a simple, practical guide to assess Doctor Patient Communication in daily consultation practice.

Does Weather Matter? The Effect of Weather Patterns and Temporal Factors on Pediatric Orthopedic Trauma Volume.

Objectives:Orthopaedists often speculate how weather and school schedule may influence pediatric orthopedic trauma volume, but few studies have examined this. This study aims to determine: how do weather patterns, day, month, season and public school schedule influence the daily frequency of pediatric orthopedic trauma consults and admissions?Methods:With IRB approval, orthopedic trauma data from a level 1 pediatric trauma center, including number of daily orthopedic trauma consults and admissions, were collected from July 2009 to March 2012. Historical weather data (high temperatures, precipitation and hours of daylight), along with local public school schedule data were collected for the same time period. Univariate and multivariate regression models were used to show the average number of orthopedic trauma consults and admissions as a function of weather and temporal variables.Results:High temperature, precipitation, month and day of the week significantly affected the number of daily consults and admissions. The number of consults and admissions increased by 1% for each degree increase in temperature (p=0.001 and p<0.001, respectively), and decreased by 21% for each inch of precipitation (p<0.001, p=0.006). Daily consults on snowy days decreased by an additional 16% compared to days with no precipitation. November had the lowest daily consult and admission rate, while September had the highest. Daily consult rate was lowest on Wednesdays and highest on Saturdays. Holiday schedule was not independently significant.Conclusion:Pediatric orthopedic trauma consultations and admissions are highly linked to temperature and precipitation, as well as day of the week and time of year.

Internet services in academic libraries

Purpose The use of the internet and World Wide Web to source information is now an emerging practice in developing countries and seems to be obscuring the use of printed resources in libraries. This paper aims to investigate the impacts of internet services on the use of prints in academic libraries in Nigeria. Design/methodology/approach The design of the study was ex post facto. The population of the study was the 131,670 students registered in the library from 2005 to 2014 academic sessions. The instruments for data collection were documentary records, oral interviews and observations. Statistics of past physical transactions at the Nnamdi Azikiwe Libraries University of Nigeria, Nsukka, were consulted and adapted for the study. Tables, graphs and a benchmark for assessment guided the analysis and discussion of the data. Findings Readers’ registrations, average daily readership and consultation of theses/dissertations were among the physical services that are multiplying and exerting pressures on existing facilities in the library. Books and periodicals consulted were constantly declining since the advent of internet services. Academic libraries in Nigeria should be adequately funded to sustain information and communication technology (ICT) backbone for internet usage and better marketing and stabilization of library services to retain users in academic libraries. Practical implications Increased availability of full-text online could force academic libraries in developing countries to cancel much of their online subscriptions. Serious efforts must be embarked by academic libraries to bring back the users to the library. Originality/value This article is the first to investigate the impacts of internet usage on printed resources in academic libraries in Nigeria. The originality lies in its contribution to internet use on information resources in academic libraries in developing regions.