Scheduled Follow-up Research Articles

Validation of a novel risk score to predict early and late recurrence in solitary fibrous tumour.

Current risk models in solitary fibrous tumour (SFT) were developed using cohorts with short follow-up and cannot reliably identify low-risk patients. We recently developed a novel risk model (G-score) to account for both early and late recurrences. Here, we aimed to validate the G-score in a large international cohort with long-term follow-up. Data were collected from nine sarcoma referral centres worldwide. Recurrence-free interval (RFi) was the primary endpoint. The cohort comprised 318 patients with localised extrameningeal SFTs. Disease recurrence occurred in 96 patients (33%). The estimated 5-year RFi rate was 72%, and the 10-year RFi rate was 52%. G-score precisely predicted recurrence risk with estimated 10-year RFi rate of 84% in low risk, 54% in intermediate risk and 36% in high risk (p < 0.001; C-index 0.691). The mDemicco (p < 0.001; C-index 0.749) and SalasOS (p < 0.001; C-index 0.674) models also predicted RFi but identified low-risk patients less accurate with 10-year RFi rates of 72% and 70%, respectively. G-score is a highly significant predictor of early and late recurrence in SFT and is superior to other models to predict patients at low risk of relapse. A less intensive follow-up schedule could be considered for patients at low recurrence risk according to G-score.

MAC-spinal meningioma score: A proposal for a quick-to-use scoring sheet of the MIB-1 index in sporadic spinal meningiomas.

ObjectiveMIB-1 index is an important predictor of meningioma progression. However, MIB-1 index is not available in the preoperative tailored medical decision-making process. A preoperative scoring sheet independently estimating MIB-1 indices in spinal meningioma (SM) patients has not been investigated so far.MethodsBetween 2000 and 2020, 128 patients with clinical data, tumor imaging data, inflammatory laboratory (plasma fibrinogen, serum C-reactive protein) data, and neuropathological reports (MIB-1, mitotic count, CD68 staining) underwent surgery for spinal WHO grade 1 and 2 meningioma.ResultsAn optimal MIB-1 index cut-off value (≥5/<5) predicting recurrence was calculated by ROC curve analysis (AUC: 0.83; 95%CI: 0.71-0.96). An increased MIB-1 index (≥5%) was observed in 55 patients (43.0%) and multivariable analysis revealed significant associations with baseline Modified McCormick Scale ≥2, age ≥65, and absence of calcification. A four-point scoring sheet (MAC-Spinal Meningioma) based on Modified McCormick, Age, and Calcification facilitates prediction of the MIB-1 index (sensitivity 71.1%, specificity 60.0%). Among those patients with a preoperative MAC-Meningioma Score ≥3, the probability of a MIB-1 index ≥5% was 81.3%.ConclusionThis novel score (MAC-Spinal Meningioma) supports the preoperative estimation of an increased MIB-1 index, which might support preoperative patient-surgeon consultation, surgical decision making and enable a tailored follow-up schedule or an individual watch-and-wait strategy.

Risk of progression following a negative biopsy in prostate cancer active surveillance

BackgroundCurrently, follow-up protocols are applied equally to men on active surveillance (AS) for prostate cancer (PCa) regardless of findings at their initial follow-up biopsy. To determine whether less intensive follow-up is suitable following negative biopsy findings, we assessed the risk of converting to active treatment, any subsequent upgrading, volume progression (>33% positive cores), and serious upgrading (grade group >2) for negative compared with positive findings on initial follow-up biopsy.Methods13,161 men from 24 centres participating in the Global Action Plan Active Surveillance Prostate Cancer [GAP3] consortium database, with baseline grade group ≤2, PSA ≤ 20 ng/mL, cT-stage 1–2, diagnosed after 1995, and ≥1 follow-up biopsy, were included in this study. Risk of converting to treatment was assessed using multivariable mixed-effects survival regression. Odds of volume progression, any upgrading and serious upgrading were assessed using mix-effects binary logistic regression for men with ≥2 surveillance biopsies.Results27% of the cohort (n = 3590) had no evidence of PCa at their initial biopsy. Over 50% of subsequent biopsies in this group were also negative. A negative initial biopsy was associated with lower risk of conversion (adjusted hazard ratio: 0.45; 95% confidence interval [CI]: 0.42–0.49), subsequent upgrading (adjusted odds ratio [OR]: 0.52; 95%CI: 0.45–0.62) and serious upgrading (OR: 0.74; 95%CI: 0.59–92). Radiological progression was not assessed due to limited imaging data.ConclusionDespite heterogeneity in follow-up schedules, findings from this global study indicated reduced risk of converting to treatment, volume progression, any upgrading and serious upgrading among men whose initial biopsy findings were negative compared with positive. Given the low risk of progression and high likelihood of further negative biopsy findings, consideration should be given to decreasing follow-up intensity for this group to reduce unnecessary invasive biopsies.

Risk Factors for Fear of Recurrence in Head and Neck Cancer Patients.

Fear of recurrence (FoR) affects the quality of life of head and neck cancer survivors. Identification of factors predisposing to FoR may help to recognize and treat patients at risk. For this exploratory study, 101 disease-free head and neck cancer survivors completed a cross-sectional survey in 2017 that included the FoR questionnaire at a random point in time during their follow-up. Additionally, the patients were asked to choose their favorite among four follow-up schedules with or without systematic imaging and varying frequency of visits. Elevated FoR was present in 36.6% of patients. Females and patients ≤65 years showed significantly higher FoR overall scores than males (score difference 3.40; CI 0.49-6.32; p=0.022) and patients >65 years (score difference 4.25; CI 1.58-6.92; p=0.002). A history of cancer recurrence or second primary malignancy increased the relative risk (RR) for elevated FoR (RR 1.7; CI 1.01-2.86; p=0.046). Tumor stage and treatment modality were not significantly associated with elevated FoR or FoR overall score. Higher FoR overall scores were recorded in patients who favored intensive follow-up plans (mean overall FoR score 18 vs. 15; SD 7.7; p=0.076) and systematic imaging in follow-up (17 vs. 13, SD 7.1; p=0.034). Fear of recurrence in head and neck cancer patients is associated with female sex, younger age, and history of a past recurrence or second primary malignancy. Due to its high prevalence, it should be addressed in clinical practice and future research. NA Laryngoscope, 133:1630-1637, 2023.

What’s New in Hip Replacement

What’s New in Hip Replacement

American Association of Endocrine Surgeons Guidelines for Adrenalectomy

Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications. To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy. A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included. Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics. Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

Symptoms and diagnosis of local recurrence after rectal cancer treatment

Aim The prognosis for local recurrence after rectal cancer treatment is poor. A minority of patients are eligible for surgery with curative intent, which could possibly be improved by earlier detection. The aim of this study was to determine symptoms at presentation and how local recurrence was diagnosed, and to identify alarm symptoms for local recurrence as opposed to symptoms found among patients after surgery for rectal cancer in general. Methods In a population-based retrospective cohort (cohort A), all patients who had undergone resection surgery for rectal cancer in the region of Västra Götaland, Sweden, diagnosed 2010–2014, were identified through the Swedish ColoRectal Cancer Registry. After a follow-up period of at least five years, medical records were reviewed to identify patients diagnosed with local recurrence. Data on symptoms, diagnostic procedures and treatment of local recurrence were retrieved. A prospective cohort of patients who had undergone surgery for rectal cancer without local recurrence (the QoLiRECT-study, cohort B) was used for comparison regarding symptoms at two years after treatment. Results Cohort A consisted of 1208 patients, out of whom 78 (6%) were diagnosed with local recurrence. Forty-six patients were diagnosed between scheduled follow-up visits. Fifty-eight patients were symptomatic at the time of diagnosis, and the most common symptoms were pain, bleeding and urogenital symptoms. Pain was more common in patients with local recurrence when comparing cohort A with cohort B. Conclusion A majority of patients with local recurrence were diagnosed outside of the scheduled follow-up. Most of the patients were symptomatic at diagnosis. Symptoms were common in patients after rectal cancer surgery in general, however pain was more common in patients with local recurrence and could represent an alarm symptom.

The effect of a tight control regime with monthly follow-up on remission rates and reported pain in early rheumatoid arthritis.

To determine whether a tight control (TC) regime with monthly consultations to the physician for the first 6months, could increase remission rate and improve reported pain of patients with early rheumatoid arthritis (RA). In this single-centre, TC study, with monthly visits to the physician, a cohort of 100 patients with early RA was consecutively included. They were compared with a reference cohort of 100 patients from the same clinic that had been conventionally managed. The patients were followed for 2years. The patients in the TC cohort had lower 28- joints disease activity score (DAS28) at three, six, 12 and 24months, compared with the conventionally managed cohort, p≤0.001. At 12months, 71% in the TC cohort versus 46% in the conventional cohort were in remission (DAS28<2.6) and at 24months 68% versus 49% respectively, p<0.05. The TC cohort reported less pain at three, six, 12 and 24months, p<0.001. Multiple logistical regression analyses adjusted for, respectively, age, disease duration, pharmacological treatment, DAS28 and visual analogue scale pain at inclusion, revealed that participation in the TC cohort had an independent positive association with remission at 12 and 24months and with acceptable pain at 24months. The intensive follow-up schedule for patients with early RA improved remission and led to improvement in reported pain and physical function. The positive effect of a TC regime in early disease may be due to increased empowerment, developed by meeting health professionals frequently.

Effect of adherence to follow-up on recovery from moderate acute malnutrition among under-fives in a supplementary feeding programme

Introduction: Supplementary feeding programme is a strategy for managing underfives with moderate acute malnutrition (MAM). This study aimed to determine the effect of adherence to follow-up on recovery from MAM among under-fives. Methods: A clinical trial to evaluate the effectiveness of daily supplementary rations of a standardised milk-based formulation (SMBF), standardised non-milk-based formulation (SNMBF), and hospital-based formulation (HBF) on recovery from MAM over a four months period was conducted among eligible children aged 6 – 59 months. Recovery from MAM among participants was determined based on their status of adherence to follow-up at week 16. It was deemed statistically significant if p-value was &lt;0.05. Results: Of the 157 children evaluated, 41/54 (75.9%) who received the SMBF, 32/57 (56.1%) who received the SNMBF, and 22/46 (47.8%) who received the HBF had good adherence. Adherence to follow-up was significantly higher with SMBF than SNMBF and HBF (χ²=8.923; p=0.012). In all, 95/157 (60.5%) had good adherence to follow-up with 73/95 (76.8%) recovery from MAM against 42/62 (67.7%) recovery in those with poor adherence (p=0.208). Conclusion: The status of adherence to scheduled follow-up was not significantly associated with recovery from MAM among under-fives enrolled in the supplementary feeding programme. Nevertheless, efforts at promoting adherence to scheduled follow-up visits should be sustained.

EP-593 Blind loop mucocele of a side-to-end colorectal anastomosis as a rare cause of large bowel obstruction

Abstract Background Large bowel obstruction (LBO) after colorectal surgery draws wide differentials. Very few reports of LBO secondary to closed loop mucocele have been published. To our knowledge, LBO due to mucocele of the blind colonic limb of a side-to-end colorectal anastomosis has not been described. Case Details A 57-year-old man presented with pain, gradual abdominal distension and one week history of constipation. He had extensive surgical history – colo-vesical fistula takedown, sigmoid resection and Hartmann type end colostomy followed by reversal, and mesh repair of incisional ventral hernia among others. Notably, a side-to-end configuration was fashioned as a descending colo-rectal anastomosis. CT, followed by MRI scans, of the abdomen and pelvis respectively suggested a mucus-filled short blind colonic bowel segment compressing the anastomotic site as the cause of large bowel obstruction proximal to the site. On flexible sigmoidoscopy under general anaesthesia, external compression of the rectum with narrowing of the lumen was noted. Transrectal needle aspiration of the blind colonic segment yielded 145 mL of mucoid fluid and allowed proximal examination. Anastomotic site was of normal calibre. The patient's symptoms improved and he was discharged with scheduled outpatient follow-up. Gastrografin enema post-discharge demonstrated an end-to-side rectosigmoid anastomosis with local rectal stenosis and showed the blind loop had emptied. Conclusion This case highlights that blind colonic loop mucoceles in colorectal anastomosis can rarely cause obstruction and endoscopic management is feasible when accurate diagnosis is confirmed on imaging.

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

BackgroundAn effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.MethodsFive databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.ResultsFifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.ConclusionAlthough poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Effectiveness of clinical and instrumental follow-up for cutaneous melanoma

IntroductionFollow-up guidelines for melanoma greatly differ in the methods of screening for recurrence, and timing and duration of the follow up, with many areas of controversy and a lack of general consensus.The aims of this study are to present our protocol and case series for follow up and to summarize and discuss current literature on melanoma follow-up guidelines/recommendations in different countries. MethodsWe retrospectively reviewed 539 patients operated for melanoma between 2004 and 2013 at the same Institution. Data on the diagnostic role of the different clinical and instrumental detection methods were adjusted for sex, age at diagnosis, staging and evaluated by Fisher's exact test and multivariate analysis.Recommendations from the literature were summarized and discussed. ResultsLocal recurrences and second melanoma were always identified through physical examination, irrespectively of melanoma staging. Regional metastases were most often identified through physical examination and ultrasound, being more frequent in stage II and III, while distant metastases were most often identified through CT scans.Surveillance follow-up schedules vary significantly depending on country, physician specialty, and stage of disease, with a lack of evidence on the efficacy of the different schemes. Similarities and controversies in the different follow-up protocols are presented and discussed. ConclusionOur clinical series showed that physical examination is very powerful in identifying local recurrences and second melanomas. Physical examination and ultrasound are equally powerful in identifying regional metastases, and alternating them over time could allow to reduce the number of follow-up visits. CT scans, differently from chest x-ray, showed a high power in identifying distant metastases.Surveillance follow-up schedules in the literature vary significantly depending on country, physician specialty, and stage of disease, with a lack of evidence on the efficacy of the different schemes. Standard protocols are desirable for a better evaluation of results.

Assessing Trifecta Achievement after Percutaneous Cryoablation of Small Renal Masses: Results from a Multi-Institutional Collaboration.

Background and Objectives: To assess efficacy and safety of Percutaneous Cryoablation (PCA) of small renal masses (SRMs) using Trifecta outcomes in a large cohort of patients who were not eligible for surgery. Materials and methods: All PCAs performed in four different centers between September 2009 and September 2019 were retrospectively evaluated. Patients were divided in two different groups depending on masses dimensional criteria: Group-A: diameter ≤ 25 mm and Group-B: diameter > 25 mm. Complications rates were reported and classified according to the Clavien–Dindo system. The estimate glomerular filtration rate (eGFR) was calculated before PCA and during follow-up schedule. Every patient received a Contrast Enhanced Ultrasound (CEUS) evaluation on the first postoperative day. Radiological follow-up was taken at 3, 6, and 12 months for the first year, then yearly. Radiological recurrence was defined as a contrast enhancement persistence and was reported in the study. Finally, Trifecta outcome, which included complications, RFS, and preservation of eGFR class, was calculated for every procedure at a median follow-up of 32 months. Results: The median age of the patients was 74 years. Group-A included 200 procedures while Group-B included 140. Seventy-eight patients were eligible for Trifecta evaluation. Trifecta was achieved in 69.6% of procedures in Group-A, 40.6% in Group-B (p = 0.02). We observed an increased rate of complication in Group-B (13.0% vs. 28.6; p < 0.001). However, 97.5% were <II Clavien–Dindo grade. No differences were found between the two groups regarding eGFR before and after treatment. Further, 24-months RFS rates were respectively 98.0% for Group-A and 92.1% in Group-B, while at 36 months were respectively 94.5% and 87.5% (p = 0.08). Conclusions: PCA seems to be a safe and effective treatment for SRM but in the need of more strict dimensional criteria to achieve a higher possible success rate.

How to Improve Audiology Services: The Patient Perspective

How to Improve Audiology Services: The Patient Perspective

Recent Advances in the Diagnosis and Management of High-Risk Cutaneous Squamous Cell Carcinoma.

Simple SummaryCutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer. Although most cSCCs are effectively treated with surgery, there are some tumors at higher risk for relapse, progression to nodal metastasis, or, rarely, death. An important issue concerns the early diagnosis and appropriate treatment of these few high-risk cSCCs, as they are associated with poorer prognosis and may more frequently progress to advanced cSCCs. This review discusses the characteristics of high-risk cSCC and how to identify and manage patients with these tumors.High-risk cSCC is defined as invasive cSCC staged as N0 (without detectable regional lymph nodes) and M0 (without distant metastasis), that has features associated with a higher risk of poorer prognosis. The focus of this review is on the recent advances in the diagnosis and management of high-risk cSCC. The interest in high-risk cSCC relies on its higher risk of progression to advanced cSCC, as it represents the main pool of cSCCs that give rise to advanced tumors. Assessment of the risk is thus particularly relevant for common cSCC to identify the few with a high-risk risk of local recurrence, metastasis, or disease-specific death among all other low-risk tumors. The timely diagnosis and effective treatment of high-risk cSCCs may halt their further progression and aim to prevent and lower the incidence of advanced cSCCs. Clearance of the tumor with negative surgical margins is the main goal of surgery, which is the primary treatment of cSCC. It seems that it is difficult to discern the group of high-risk cSCCs that may benefit from adjuvant RT, as a universal beneficial effect for a cSCC with any high-risk factor which was resected with clear surgical margins has not been established. In the case of a high-risk cSCC with positive margins after surgery, and re-excision not feasible, post-operative radiotherapy is performed when possible. Recommendations on further management are discussed. Regarding the follow-up of patients diagnosed with high-risk cSCC, factors to consider regarding the frequency and intensity of the follow-up schedule include the risk and possible time of occurrence of metastasis from cSCC.

The Impact of Clinical Follow-Up After Revascularization on the Outcomes of Patients with Chronic Limb Threatening Ischemia

Guidelines for optimal follow-up for patients undergoing lower extremity revascularization (LER) for peripheral arterial disease recommend multiple visits with imaging during the first year followed by yearly monitoring thereafter. Critical limb-threatening ischemia (CLTI) patients are at a greater risk for mortality and limb amputation than claudicants and thus necessitate closer monitoring. The goal of this article is to study the effects of compliance with follow-up after revascularization for patients with CLTI on major amputation rates and mortality. A single-center retrospective chart review of consecutive patients undergoing LER for CLTI was performed. Patients were stratified based on compliance with follow-up to compliant or noncompliant cohorts. Patient characteristics, reinterventions, and perioperative and long-term outcomes were compared between the 2 groups. There were 356 patients undergoing LER and 61% (N=218) were compliant. There was no significant difference in baseline characteristics between the 2 groups. Noncompliant patients were more likely to undergo endovascular interventions compared to compliant patients (92.8% vs. 79.4%, P=0.03). There was no difference in perioperative outcomes between the 2 groups with overall 30-day mortality of 0.6%. After mean follow-up of 2.7years, compliant patients had greater ipsilateral reintervention rates (49.1% vs. 34.1%, P=0.005) and overall reintervention rates (61% vs. 44.2%, P=0.002) compared to noncompliant patients. There was no significant difference in mortality or ipsilateral major amputations between the 2 groups. Patients who were compliant with follow-up after LER for CLTI underwent more reinterventions with no difference in mortality or major limb amputation. Further research regarding the threshold for reintervention and the optimal schedule for follow-up in patients with CLTI is needed.

Case Series of Patients With Hereditary Benign Intraepithelial Dyskeratosis.

The purpose of this retrospective case series was to compare the outcomes of different treatment options for patients diagnosed with hereditary benign intraepithelial dyskeratosis (HBID). The study is designed as a single-institution retrospective chart review of patients who were clinically diagnosed with HBID during their care at the Duke Eye Center. Patient demographics were obtained, and disease course after different therapies was analyzed. Seventeen patients were diagnosed with HBID. 52.9% (9/17) of patients identified with HBID reported Native American ancestry. Medical therapy alone failed to reduce the size or number of corneal lesions in any patient identified in this study. Ten of the 17 patients required surgical intervention. Two eyes received corneal biopsies, 3 eyes received a full conjunctival lesion excision with amniotic membrane grafting, 12 eyes received superficial keratectomy with amniotic membrane grafting, and 1 eye received keratoprosthesis. Lesion recurrence was seen in 9 of the 10 patients treated with surgical excision with an average time to recurrence of 1.5 and 2 months for conjunctival excisions and superficial keratectomy, respectively, when excluding patients who missed scheduled postoperative follow-up appointments. Hereditary benign intraepithelial dyskeratosis is a rare and poorly understood disorder that predominantly affects people with Native American ancestry. Medical therapy only provides symptomatic relief, and patients who receive surgical excision almost always develop recurrence. As a result, we recommend future investigations focus on identifying the optimal surgical technique and timing to limit the morbidity of HBID and improve outcomes.

Torus fractures of the distal radius: time to focus on symptomatic management

The torus (buckle) fracture of the distal radius is one of the most common fractures in children. This fracture is inherently stable and carries an excellent prognosis,1 and several studies have supported the use of a removable splint primarily for symptom relief and discretionary follow-up.2–5 In The Lancet, Daniel Perry and colleagues6 report the results of a pragmatic randomised trial that was designed to challenge the need for any immobilisation. At 23 emergency departments across the UK, 965 children (379 [39%] female and 586 [61%] male) from age 4 years to 15 years with a torus fracture of the distal radius, were randomly assigned to either an offer of a bandage and no scheduled follow-up (n=489) or rigid immobilisation (cast or splint; n=476) with follow-up as per the standard practice of the treating centre.

Accuracy Assessment of Outpatient Telemedicine Encounters at an Academic Ophthalmology Department

Abstract Purpose We assess the clinical accuracy of direct-to-patient real-time outpatient video visit encounters at our eye center. Design This was a retrospective longitudinal study. Subjects and Methods Patients who completed a video visit over a 3-week period between March and April 2020 were included. Accuracy assessment was determined by comparing diagnosis and management from the video visit with subsequent in-person follow-up over the next year. Results A total of 210 patients (mean age 55±18 years) were included, of whom 172 (82%) were recommended a scheduled in-person follow-up encounter after their video visit. Among the 141 total patients who completed in-person follow-up, 137 (97%) had a diagnostic agreement between telemedicine and in-person evaluation. Management plan agreed for 116 (82%), with the remainder of visits either escalating or deescalating treatment upon in-person follow-up with little substantive change. Compared with established patients, new patients had higher diagnostic disagreement following video visits (12 vs. 1%, p=0.014). Acute visits trended toward more diagnostic disagreement compared with routine visits (6 vs. 1%, p=0.28) but had a similar rate of management change on follow-up (21 vs. 16%, p=0.48). New patients were more likely to have early unplanned follow-up than established patients (17 vs. 5%, p=0.029), and acute video visits were associated with unplanned early in-person assessments compared with routine video visits (13 vs. 3%, p=0.027). There were no serious adverse events associated with the use of our telemedicine program in the outpatient setting. Conclusions Video visits had high diagnostic and management agreement with subsequent in-person follow-up encounters.

Challenges for Primary Caregivers during the COVID-19 Pandemic in Accessing Health Care of Children with Chronic Diseases under Periodic Follow-up at a Tertiary Care Hospital in South India

Introduction: Challenges faced by the primary caregivers during the COVID-19 pandemic help to identify their needs and health seeking behavior during pandemic. Objectives: (1) To describe the factors associated with periodic follow-up at the hospital which posed as difficulties to their primary caregivers during the COVID-19 pandemic. (2) To identify the measures adopted by these primary caregivers to overcome those difficulties. Materials and Methods: This hospital-based cross-sectional observational study was conducted from May to August 2021 among 57 primary caregivers of children with chronic diseases registered before March 1, 2020, who were under periodic follow-up in our pediatrics department. Data were collected by direct or telephonic interview using a predesigned semi-structured questionnaire and analyzed using descriptive and inferential statistics like mean, standard deviation, proportions and paired "t"-test using Epi info and IBM SPSS trial version 28.0. Results: Frequency of hospital visits of 14 (24.6%) subjects were reduced during the COVID pandemic compared to the prepandemic period. During the COVID pandemic, 42 (73.7%) subjects had faced transportation difficulties, 23 (40.3%) had faced financial difficulties, 22 (38.6%) had skipped their scheduled follow-up visits and around 31.6% of them have feared of contracting COVID. None had availed telemedicine consultation for their children either before or during the pandemic. Conclusions: Difficulties faced in transportation, fear of contracting COVID, financial difficulties, and lack of awareness of teleconsultation services were identified as their major obstacles.