Doctor's Office Research Articles

Assessment of Value of Neighborhood Socioeconomic Status in Models That Use Electronic Health Record Data to Predict Health Care Use Rates and Mortality

Prediction models are widely used in health care as a way of risk stratifying populations for targeted intervention. Most risk stratification has been done using a small number of predictors from insurance claims. However, the utility of diverse nonclinical predictors, such as neighborhood socioeconomic contexts, remains unknown. To assess the value of using neighborhood socioeconomic predictors in the context of 1-year risk prediction for mortality and 6 different health care use outcomes in a large integrated care system. Diagnostic study using data from all adults age 18 years or older who had Kaiser Foundation Health Plan membership and/or use in the Kaiser Permantente Northern California: a multisite, integrated health care delivery system between January 1, 2013, and June 30, 2014. Data were recorded before the index date for each patient to predict their use and mortality in a 1-year post period using a test-train split for model training and evaluation. Analyses were conducted in fall of 2019. One-year encounter counts (doctor office, virtual, emergency department, elective hospitalizations, and nonelective), total costs, and mortality. A total of 2 951 588 patients met inclusion criteria (mean [SD] age, 47.2 [17.4] years; 47.8% were female). The mean (SD) Neighborhood Deprivation Index was -0.32 (0.84). The areas under the receiver operator curve ranged from 0.71 for emergency department use (using the LASSO method and electronic health record predictors) to 0.94 for mortality (using the random forest method and electronic health record predictors). Neighborhood socioeconomic status predictors did not meaningfully increase the predictive performance of the models for any outcome. In this study, neighborhood socioeconomic predictors did not improve risk estimates compared with what is obtainable using standard claims data regardless of model used.

Osteoarthritis: New Strategies for Transport and Drug Delivery Across Length Scales.

Osteoarthritis (OA) is the fourth leading cause of disability in adults. Yet, few viable pharmaceutical options exist for pain abatement and joint restoration, aside from joint replacement at late and irreversible stages of the disease. From the first onset of OA, as joint pain increases, individuals with arthritis increasingly reach for drug delivery solutions, from taking oral glycosaminoglycans (GAGs) bought over the counter from retail stores (e.g., Costco) to getting injections of viscous, GAG-containing synovial fluid supplement in the doctor's office. Little is known regarding the efficacy of delivery mode and/or treatment by such disease-modulating agents. This Review addresses the interplay of mechanics and biology on drug delivery to affected joints, which has profound implications for molecular transport in joint health and (patho)physiology. Multiscale systems biology approaches lend themselves to understand the relationship between the cell and joint health in OA and other joint (patho)physiologies. This Review first describes OA-related structural and functional changes in the context of the multilength scale anatomy of articular joints. It then summarizes and categorizes, by size and charge, published molecular transport studies, considering changes in permeability induced through inflammatory pathways. Finally, pharmacological interventions for OA are outlined in the context of molecular weights and modes of drug delivery. Taken together, the current state-of-the-art points to a need for new drug delivery strategies that harness systems-based interactions underpinning molecular transport and maintenance of joint structure and function at multiple length scales from molecular agents to cells, tissues, and tissue compartments which together make up articular joints. Cutting edge and cross-length and -time scale imaging represents a key discovery enabling technology in this process.

Trends in place of early-season influenza vaccination among adults, 2014-15 through 2018-19 influenza seasons—The importance of medical and nonmedical settings for vaccination

Annual vaccination is the most effective strategy for preventing influenza. We assessed trends and demographic and access-to-care characteristics associated with place of vaccination in recent years. Data from the 2014-2018 National Internet Flu Survey were analyzed to assess trends in place of early-season influenza vaccination during the 2014-15 through 2018-19 seasons. Multivariable logistic regression was conducted to identify factors independently associated with vaccination settings in the 2018-19 season. Among vaccinated adults, the proportion vaccinated in medical (range: 49%-53%) versus nonmedical settings (range: 47%-51%) during the 2014-15 through 2018-19 seasons were similar. Among adults aged ≥18 years vaccinated early in the 2018-19 influenza season, a doctor's office was the most common place (34.4%), followed by pharmacies or stores (32.3%), and workplaces (15.0%). Characteristics significantly associated with an increased likelihood of receipt of vaccination in nonmedical settings among adults included household income ≥$50,000, having no doctor visits since July 1, 2018, or having a doctor visit but not receiving an influenza vaccination recommendation from the medical professional. Place of early-season influenza vaccination among adults who reported receiving influenza vaccination was stable over 5 recent seasons. Both medical and nonmedical settings were important places for influenza vaccination. Increasing access to vaccination services in medical and nonmedical settings should be considered as an important strategy for improving vaccination coverage.

Automatic Non-Contact Fever Detector to Prevent COVID-19 Spread in Public Places

The COVID-19 virus has spread around the world and over 22 million people were diagnosed with the virus. Fevers are one of the top three symptoms of coronavirus, the others being coughs and shortness of breath. A critical component to prevent the spread of COVID-19 is to quickly detect fevers in public places, including hospitals, doctor offices, elder care centers, schools, gyms, movie theaters, restaurants, etc. Today, thermometers can be used in these places, but they require manual operation by dedicated health workers. To make temperature measurement an automatic process, an automatic non-contact fever detector is developed. The fever detector consists of several components: a clinically tested and precisely calibrated thermometer to guarantee accuracy and reliability, a motion sensor to detect the readiness of temperature taking, a relay-based trigger circuit to replace the manual trigger of the thermometer, and a DC-to-DC regulator to replace batteries in the thermometer. LCD signals and the buzz signal from the thermometer, are used to determine the measurement results. Lighting and sound signals are used as indication of normal temperature or fever. All the functions of the detector are controlled by a microcontroller. The detector has been thoroughly tested for continuous operation. Once widely used, the detector will help to detect fevers in public places and prevent the spread of the COVID-19 virus. .

The Use of Social Network in Daily Pediatric Practice and Education: Turkish Pediatric Atelier.

Using social media applications in pediatric education is not outdated, and its effectiveness has not been tested yet. For this reason, we shared the first results of the Pediatric Atelier experience that we realized through telegram application. We make an online survey to investigate the needs, requirements, pleasure, and suggestions of members through a web-based questionnaire. This cross-sectional survey study was delivered only to participants who were members of the workshop via their email addresses. Online questionnaires organized using Google Forms were sent to pediatric workshop members between March and June 2019. The questionnaire consisted of questions that measured the participants' basic demographic data, the use of the workshop, and the overall impact of the workshop on their professional behavior. While the institutions and positions of the participants were recorded, no other personal data (such as address and telephone) were collected. Among the 997 members, 417 (42%) of them answered the questionnaire. Respondents included 300 (72%) pediatrician, 21 (5%) pediatric subspeciality fellows, and 75 (18%) pediatric subspecialists. Of the 417 respondents, 217 (52%) were working in Istanbul, and 200 (48%) were working in other cities of Turkey. Among the responders, 233 (56%) were working in private hospitals or doctor offices. A total of 520 cases were consulted in 241 days of study period. Most consultations (n = 309, %59) were made from the Istanbul metropolitan area, and 203 (40%) consultations were from other cities of Turkey. The most frequently consulted departments were Pediatric infectious diseases: 166 (32%), Pediatric hematology and oncology: 56 (11%), and Neonatology: 43 (8%). Of the 520 consulted cases, 44 (8%) were related to life-threatening events, and 25 of them were hospitalized in the intensive care units, and 6 of them were required surgical operations. Of the 94% of responders thought this platform was useful and 82% of them stated that the case counseling part of the atelier was the most useful part. We think that the development of technology and artificial intelligence may lead to the usage of on-line platforms or systems in clinical medical practice. Clinical Trial Registration (if any). Registry name, registration number, web link to study on registry, and data sharing statement.

Inside the doctor's office. Talking about intersex with Italian health professionals

This article explores how health professionals in Italy understand variations of sex characteristics (VSC), also referred to as intersex and/or disorders of sex development (DSD). With estimates of VSC frequency ranging from 0.018% to 1.7%, only a handful of highly specialised medical doctors are considered DSD experts. When addressing the daily health management of children and families who do not live near specialist DSD centres, these experts may refer individuals to the nearest health professional that Italian health services provides, opening up questions regarding how these professionals might act and react when faced with VSC. In this analysis of interview data from 65 Italian general practitioners, paediatricians and psychologists, we address two themes. The first theme discusses participants’ previous experiences and case management, with a focus on social, medical and gender biases. The second theme examines health professionals’ opinions and perspectives on ongoing conflicts concerning current best care practices. Our results highlight health professionals’ cultural and gendered biases, confirming the need to develop specific professional training, guidelines and policies to improve the healthcare of people with VSC.

Using human-centered design to improve the quality of vaccine communication

Abstract In recent years, one-on-one vaccine communication has become more important that ever. Research has shown that an intact parent-paediatrician relationship is the most important predictor for positive attitudes toward immunisation. Yet, much of the discussion around the benefits of vaccines and the risk of vaccine preventable diseases has also moved online. New communication channels and discussion fora are evolving rapidly, and their use may differ significantly among different sociodemographic groups. These recent developments have implications for the work of policy makers. Public health messaging will need to be tailored to different subsectors of the population, such as those primarily interested in maternal-infant care, adolescent health, or travel medicine. Mobile applications, telemedicine, video blogs, and other digital fora provide room for science-informed vaccine communication extending beyond the brief conversations at the doctor's office. Each mode of communication may have its own impact, but pediatricians will need to get involved in bridging the communication gap between policy makers and public health agencies on one hand, and children and families on the other. We will discuss the results of recent projects undertaken by the Vienna Vaccine Safety Initiative using the innovation technique of Design Thinking to move the experience of children and their caretakers back into the center of the conversation. We will provide practical examples of human-centered design i) to improve the understanding of individual-level disease severity in flu patients, ii) to empower parents to keep the vaccination records in their family up-to-date, iii) to improve safety reporting at the point of care, and iv) to enable migrant populations to report missed immunizations and other health needs. We will invite active discussion with the audience while providing critical analysis of lessons learnt and implications for health policy and future research.

Stretch reflexes

Many of us know about stretch reflexes from the doctor's office, when a physician taps the tendon near our kneecap to elicit a quick knee extension. This procedure is used as a diagnostic tool to determine the integrity of the spinal cord and the extension response it elicits may seem otherwise useless. In fact, the tendon tap taps into one aspect of a critical building block of mammalian motor control, the stretch reflexes. Stretch reflexes are often thought to quickly resist unexpected changes in muscle length via a very simple circuit in the spinal cord, and this is one circuit that the tendon tap engages. It turns out, however, that stretch reflexes support a myriad of functions and are highly flexible. Under naturalistic conditions, stretch reflexes are shaped by peripheral physiology and engage neural circuits spanning the spinal cord, brainstem and cerebral cortex. In this Primer, we outline what is currently known about stretch reflex function and its underlying mechanisms, with a specific focus on how the cascade of nested responses collectively known as stretch reflexes interact with and build off of one another to support real-world motor behavior.

Survey of the Health of Urban Residents: a Community-Driven Assessment of Conditions Salient to the Health of Historically Excluded Populations in the USA.

BackgroundData from the Survey of the Health of Urban Residents (SHUR) identified connections between police brutality and medical mistrust, generating significant media, policy, and research attention. Amidst intersecting crises of COVID-19, racism, and police brutality, this report describes survey development and data collection procedures for the SHUR.Basic ProceduresWe conducted focus groups with Black men, Latinxs, and immigrants in Allentown, Pennsylvania. Findings were used to develop and refine measures of conditions salient to the health of urban residents across the country. Quota sampling was employed; oversampling people of color and persons whose usual source of care was not a doctor’s office.Main FindingsNon-Hispanic Whites made up just under two thirds of the sample (63.65%, n = 2793). Black/African American respondents accounted for 14.2% of the sample (n = 623), while 11.62% (n = 510) were Latinx. Only 43.46% of respondents reported a doctor’s office as their usual source of care. Novel measures of population-specific stressors include a range of negative encounters with the police, frequency of these encounters, and respondents’ assessments of whether the encounters were necessary. SHUR assessed the likelihood of calling the police if there is a problem, worries about incarceration, and cause-specific stressors such as race-related impression management.Principal ConclusionsSHUR (n = 4389) is a useful resource for researchers seeking to address the health implications of experiences not frequently measured by national health surveillance surveys. It includes respondents’ zip codes, presenting the opportunity to connect these data with zip code-level health system, social and economic characteristics that shape health beyond individual factors.

Behavioral Health Needs, Barriers, and Parent Preferences in Rural Pediatric Primary Care.

The goal of this study was to examine modifiable factors related to health disparities by exploring the role of predisposing, need, and enabling characteristics on mental/behavioral health treatment-seeking behaviors in a rural sample. Parental treatment preferences and knowledge about treatment options were also examined. One hundred eighteen parents completed questionnaires assessing demographics, child prior psychological treatment, child psychological symptoms, barriers to care, mental health stigma, and willingness to seek services across settings. Questions also assessed preferences for treatment, awareness of behavioral/mental health services, and knowledge of community treatment options. Prior treatment use and stigma significantly predicted willingness to seek services in a doctor's office after controlling for predisposing (demographic) and need characteristics (psychological symptoms). Symptom severity and barriers significantly differentiated between parents who previously sought treatment or reported an unmet treatment need from those who reported no prior treatment and no treatment need. Families overwhelmingly (94%) reported a preference for individual versus group treatment, and up to 10 sessions were most commonly reported (38%) as the ideal number of sessions. Forty percent of respondents reported no knowledge of treatment options in their community. These results highlight the role of enabling characteristics (i.e., stigma, barriers to care, psychological symptoms) and prior service use in understanding parental treatment seeking in a rural sample. Overall, these results support integrated behavioral health in rural settings. Understanding modifiable factors and parent treatment preferences and knowledge may be important to increase access to services and reduce health disparities in rural areas. Future research directions are discussed.

Foot care knowledge, attitudes and practices among patients with diabetic foot and amputation in St. Kitts and Nevis.

About one-third of admissions to the surgical unit annually are diabetes foot infections in need of amputation In St. Kitts and Nevis. However, the risk factors related to diabetes foot and amputation remain unknown. This study investigated factors associated with diabetic foot and amputation (DFA). Retrospective case control study design, and purposive and quota sampling method was used to recruit the participants. Patients with and without DFA were interviewed at two main hospitals, several primary health centres, and a private doctor's office during July and August 2018. Self-development questionnaires were applied to assess patients' demographic, physical and behaviour, foot care knowledge, attitudes, and practices related to DFA. Chi-square, t-test, and multiple logistic regressions were used to analyse the data. A total of 210 patients were evaluated, 89 had DFA, while 121 did not, with a mean age of 61.10 (SD = 11.85). Participants' responses indicated good knowledge, favourable attitudes, and adequate practices related to foot care. The two items of the questionnaire, ways to maintain blood flow in the lower extremities and wash their feet daily, had significant lower score in DFA group. In multiple logistic regression, knowledge, attitudes, and practices related to foot care were not a significant predictor of DFA. Being male was a predictor of DFA than female (OR = 3.53; 95% CI = 1.65-7.57; P < .01). Participants who were currently unemployed were less likely to have DFA than those who were employed (OR = 0.38; 95% Cl = 0.17-0.86; P < .05). Comparing patients with the longest experience of diabetes mellitus (31 years or more) with those who had diabetes for the shortest period of time (between 1 and 10 years) was less likely to have DFA (OR = 0.38; 95% CI = 0.15-0.97; P = <.05). The combination of these independent variables could explain 29% of the variance in DFA. Based on these findings, strategies to prevent diabetic foot and amputation should focus on male and outdoor heavy worker, and longer duration of diabetes patients which are identified in this study.

Eliciting preferences for outpatient care experiences in Hungary: A discrete choice experiment with a national representative sample.

Patient-reported experience measures (PREMs) are central to inform on the responsiveness of health systems to citizens' health care needs and expectations. At their current form, PREMs do not reflect the weights that patients assign to varying aspects of the care experience. We aimed to investigate patients' preferences and willingness to pay (WTP) for attributes of the care experience in outpatient settings. A discrete choice experiment was conducted among a representative sample of the general adult population of Hungary (n = 1000). Choice set attributes and levels were defined based on OECD's standardized PREMs (e.g. a doctor spending enough time in consultation, providing easy to understand explanations, giving opportunity to ask questions, and involving in decision making) and a price attribute. Conditional and mixed logit analyses were conducted. WTP estimates were computed in preference and WTP space. The respondents most preferred attribute was that of a doctor spending enough time in consultation, followed by involvement in decision making. Moreover, waiting times had a less important effect on respondents' choice preference compared with aspects of the doctor-patient relationship. Estimates in the WTP space varied from €4.38 (2.85-5.90) for waiting an hour less at a doctor's office to €36.13 (32.07-40.18) for a consultation where a doctor spends enough time with a patient relative to a consultation where a doctor does not. A preference-based PREMs approach provide insight on the value patients assign to different aspects of their care experience. This can inform the decisions of policy-makers and other stakeholders to coordinate efforts and resource allocation in a more targeted manner, by acting on attributes of the care experience that have a greater impact on the implementation of patient-centered care.

Populations’ Preferences Regarding Health Care Service Delivery Patterns in Rural Areas in Western Germany—a Preliminary Survey Based on Focus Groups

Residents in rural communities increasingly face shortages in health care service. Consequently, German municipalities are driven by a strong attempt to transform care trajectories in rural areas. This qualitative study aims to identify the preferences of rural community residents towards the future service provision. Semi-structured focus group interviews were performed by means of a structured interview guide developed on the basis of a systematic literature review on expectations towards the provision of health care service. Participants were recruited in three rural communities in Western Germany. In total, three focus group interviews including 21 participants were performed. Overall, the interviews resulted in ten attributes grouped in three major domains: access to care, service delivery characteristics, and service costs. The rural population in Germany rejects outpatient care performed by hospitals and favors the provision of health care services by familiar doctor offices and occasionally interprofessional forms of outpatient care. Focus groups are an effective means to categorize preferences of the general population regarding outpatient health care service delivery patterns.

Estudo da dispensação da talidomida no tratamento da hanseníase pela Assistência Farmacêutica do Município de Araguaína-TO

A talidomida foi amplamente prescrita no passado por seus efeitos contra enjôos matinais de gravidas, no entanto, muitas crianças foram afetadas por seus efeitos teratogênicos até então desconhecidos, alguns anos depois o fármaco vem sendo utilizado no tratamento do Eritema Nodoso Hansêmico (ENH). O presente estudo visa analisar a dispensação da talidomida no tratamento da hanseníase por meio da Assistência farmacêutica (AF), que utiliza o método de consultório no município de Araguaína-TO. Objetivando averiguar a dispensação e analisar o método empregado, além de revisar o tratamento da hanseníase com a talidomida. Trata-se de um estudo retrospectivo de prontuários referentes às dispensações de talidomida no tratamento da hanseníase, obtidos pela Assistência Farmacêutica nos anos de 2013 a 2018. Através disto, foi desenvolvida uma planilha como instrumento de trabalho, onde foram obtidos os dados de cada usuário referente ao gênero, número de pacientes, idade e reações frequentes, e assim traçar o perfil do usuário em tratamento de hanseníase atendido pela AF e ressaltar o atendimento realizado no consultório farmacêutico, uma iniciativa pioneira no Brasil.

Should We Be Laughing More in Art Museums and Hospitals?

If both art and laughter are good for your health, why aren't we encouraging more humor in museums and hospitals? We are taught to approach art with awe and respect-and to treat medicine as deadly serious business. It follows, then, that overt displays of humor, such as laughing or joking in a museum, doctor's office, or hospital, are probably in bad taste. But if viewing and making art can lower rates of anxiety and depression and help soothe chronic pain-and if laughter helps blood vessels function better and improves the flow of oxygen to the heart and brain-then perhaps we unwittingly deprive our patrons and patients of an important tool in the health and wellness toolbox.

Handling of allergen immunotherapy in the COVID-19 pandemic: An ARIA-EAACI statement.

The current COVID‐19 pandemic influences many areas of social life, medical treatments and the way allergy diagnosis and treatment is performed. Allergen‐specific immunotherapy (AIT) is one of the most important treatment options for IgE‐mediated allergies and is based on immunological effects on the diseased patient. This manuscript outlines the EAACI recommendations regarding AIT during the COVID‐19 pandemic and aims at supporting allergists and all physicians performing AIT in their current daily practice with clear recommendations how to perform treatment during the pandemic and in SARS‐CoV‐2 infected patients.

Organizarea activităţii cabinetului medicului de familie în contextul epidemiologic al noului coronavirus

Organizarea activităţii cabinetului medicului de familie în contextul epidemiologic al noului coronavirus

Neuropathy Mimicking Dental Pain in a Patient Diagnosed with Lyme Disease

This report documents the case of a patient who developed neuropathy that presented as dental pain and was later diagnosed with Lyme disease. A healthy female patient presented to the endodontist with toothache symptoms. Her symptoms included intense pain in the left mandible irradiating into the temporalis area and through her neck and tingling on the lower left lip and left side of her tongue. She also reported feeling of sweats and chills the night before, as well as an altered sensation in her shoulder and arm. The pain was not alleviated by over-the-counter analgesics. Both intraoral and radiographic examinations did not reveal any abnormalities, and the patient was presented with the following differential diagnoses: cardiac issues, trigeminal neuralgia, and temporomandibular dysfunction. She presented to the emergency department at the local hospital for assessment on the same day. After some tests were performed, both a stroke and myocardial infarction were ruled out. The following morning, she noticed a bump in the posterior area of her left upper thigh where an erythema with a bull's-eye appearance was observed. She presented to her family doctor's office on the same day and was diagnosed with Lyme disease. Because Lyme disease can present with symptoms similar to a toothache, dentists should be knowledgeable of its manifestations. Lyme disease should be considered as differential diagnosis in patients who present with compatible symptoms and signs, which may occur in the orofacial region.

Effects of Collaborative Care for Comorbid Attention Deficit Hyperactivity Disorder Among Children With Behavior Problems in Pediatric Primary Care.

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Environmental changes and their impact on human behaviour - Case study of the incidence of skin cancer

Climatological research over the past two decades makes it clear that the Earth's climate will change. Climate change has many, mostly adverse, effects on the human health. Environmental anthropogenic changes represent significant health risks including factors that may increase probability and seriousness of skin cancer diseases. There are many scientific studies on skin cancer but only a few of them are focused on environment changes and their influence on the behaviour of humans, which may lead to skin cancer. The goal of the research was to analyse environment changes in the city of Brno (Czech Republic) and their influence on the behaviour of people and some skin diseases. A research hypothesis was set up that total increase in the incidence of skin diseases would be monitored. 1757 patients aged 25–65 years participated in the research. The analysis was performed based on measured (mean annual temperatures, average monthly temperatures, ultraviolet index values, and numbers of sunny days and sunny hours) data in 2011–2019. In order to monitor the trend, temperature data from 1961 to 2019 were evaluated too. The analysed data indicate that the trend of average monthly and annual temperatures observed was increasing in recent years. Moreover, based on data obtained from the analysed doctor's office it was found out that the incidence of skin diseases increased in the studied period. The main reasons to increase include excessive exposure to sun, extended average age of the population, ozone layer depletion, climatic and weather changes, increased migration and behaviour of people.