Hospital Referral Research Articles

The integration of dermatology experts into primary care to assess and treat patients with skin lesions is cost-effective: A quasi-experimental study.

The management of patients with skin changes can be challenging in primary healthcare; general practitioners (GPs) often lack the expertise to make accurate assessments and treatment decisions. The standard care pathway for skin changes can result in extended treatment times and costs. This study was designed to evaluate the cost-effectiveness of integrating a dermatologist into the primary care setting to assess and treat patients with skin disorders. The primary outcome was the incremental cost-effectiveness ratio (ICER) for each malignant or pre-malignant skin disease found and treated. The secondary outcomes included ICER for any treated skin finding, number needed to excise to find malignant or pre-malignant skin disease, number of hospital referrals required and changes in quality of life (QoL) in the presence and absence of the integration. This was a quasi-experimental cohort study conducted at three primary healthcare centres in Finland. In the two intervention centres, patients with skin findings visited a dermatologist; in the control centre they visited a GP. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER). QoL was assessed with the PROMIS v1.2, calculative EQ-5D-3L and PROMIS Anxiety 4a instruments. In total, 186 integration and 176 control patients were included. For an additional patient treated for a (pre-)malignant skin disease, the ICER was €852 lower and with any skin disease €381 lower in the integration group than with standard care. Fewer biopsies were required for each malignant or pre-malignant skin disease in the integration group compared to the control group (2.1 and 6.5 per patient; p < 0.001) and lower proportion of patients were referred to hospital (8.1 vs. 17.1%, p < 0.001). Patient QoL did not differ between groups. The integration of dermatological expertise into primary care settings is cost-effective and can streamline the management of patients with skin conditions without worsening their QoL.

Personality traits and other factors associated with psychotropic medication non-adherence at two hospitals in Uganda. A cross-sectional study

Mental illnesses, like other chronic illnesses, require medications for both immediate, short term and long-term treatment. Medication adherence is the first and most important factor for better treatment outcomes. Non-adherence to psychotropic medications is associated with relapse, readmission, and early death. Psychological factors are among the common factors associated with non-adherence. Specific personality traits moderate the beliefs about medication that influence non-adherence to medications. Sociodemographic and clinical factors can also influence non-adherence to psychotropic medications. Non-adherence to psychotropic medications is high in Africa. Still, to the best of our knowledge, there is a lack of studies on the level of psychotropic medication non-adherence and associated personality traits. The aim was to determine the prevalence of psychotropic medication non-adherence and associated personality traits among people with mental illness attending Kampala International University Teaching Hospital (KIU-TH) and Jinja Regional Referral Hospital (JRRH). This study employed a hospital-based cross-sectional design. 396 adult patients suffering from mental illness were collected from KIU-TH and JRRH outpatient clinics. Medication adherence was assessed using the Medication Adherence Rating Scale (MARS) while personality traits were assessed by the short form of the Big Five Inventory (Ten Items Personality Inventory). In our study, we first assessed sociodemographic and clinical factors influencing psychotropic medication non-adherence (confounders). A questionnaire with sociodemographic information was also used. Logistic regression was used to assess personality traits and other factors associated with psychotropic medication non-adherence. The majority of the study participants were males (59.1%), from rural areas (74.2%), with a secondary educational level (47.5%) and unemployed (44.9%). The prevalence of psychotropic medication was 46.21%. Poor family support (aOR = 6.915, CI = 3.679–12.998, P&lt;0.001), belief in witchcraft/sorcery (aOR = 2.959, CI = 1.488–5.884, P = 0.002), experiencing side effects (aOR = 2.257, CI = 1.326–3.843, P = 0.003), and substance use (aOR = 4.174, CI = 2.121–8.214, P&lt;0.001) were factors significantly associated with psychotropic medication non-adherence. The personality traits significantly associated with psychotropic medication non-adherence after controlling for the confounders were neuroticism (aOR = 7.424, CI = 3.890–14.168, P&lt;0.001) and agreeableness (aOR = 0.062, CI = 0.024–0.160, P&lt;0.001). In this study, medication non-adherence was high. Non-adherent patients were more likely to have predominant neuroticism personality traits. Non-adherence to medication was shown to be less common in individuals with agreeableness personality traits. Other factors associated with psychotropic medication non-adherence were poor social support, witchcraft beliefs, the presence of side effects, and substance use. Specific interventions should be done for patients with a high risk of being non-adherent to psychotropic medications, with the involvement of all stakeholders including caregivers, parents, tutors, and trustees.

Diagnostic trajectories of patients with rare cancer in the Netherlands: results from a nationwide cross-sectional survey.

Diagnosing rare cancers is challenging and often leads to prolonged diagnostic trajectories. This study investigated the diagnostic trajectory of patients with rare cancers in The Netherlands. Data from 1541 patients were recruited via patient advocacy in a national online survey on their diagnostic trajectory, such as first general practitioner (GP) consultation to hospital referral and number of hospital visits before final diagnosis. Differences between solid vs. non-solid tumours and EURACAN domains were explored. Diagnostic timelines varied from less than 3 months to over 12 months. Most patients (76.0%) first consulted their GP before going to a hospital. 76.3% of all patients were referred to a hospital within less than 3 months. 32.1% reported receiving an incorrect diagnosis, and 44.6% of them underwent treatment or medication for the (perceived) incorrect diagnosis. Patients with solid vs. non-solid rare cancers trajectories differed significantly for treatment hospital, route to diagnosis, correctness of initial diagnosis, and number of hospital visits before correct diagnosis (all p < 0.001). Patients with neuroendocrine (NET; 21.7%) and endocrine tumours (17.5%) experienced longer GP-to-hospital visit waiting times. Patients with non-solid cancers often received a correct diagnosis after one hospital visit (75%) when compared with patients with solid cancer (2+ = 57.7%). Those with rare skin cancer and non-cutaneous melanoma, head and neck, and thoracic cancer visited multiple hospitals before an accurate diagnosis (56.7%, 53.8%, and 50.0%). Patients with rare cancers face significant challenges with diagnostic delays and inaccuracies. Researching symptom signatures and investing in regional clinical networks might improve diagnostic timelines.

Clinical and Analytical Presentation of Central Precocious Puberty: A 20-Year Cross-Sectional Study

Objectives − This study aims to compare the clinical and analytical presentation of Central precocious puberty (CPP), considering age.Methods − An observational, cross-sectional study was conducted on children diagnosed with CPP at a level III hospital, between January 2002 and April 2022. Clinical, auxological, sociodemographic, laboratory, and imaging parameters were analyzed.Results − Out of the 52 children studied, the majority were girls (N=44). The median age of puberty onset in girls was 6.79 years and the mean age at first consultation of 8.13 years, with a significantly lower age at hospital referral (7.65 years; P=0.045) compared to boys. Idiopathic etiology was predominant in both. In girls, breast development appeared at older mean ages (P=0.009), while pubic hair growth and accelerated growth were associated with younger ages at puberty onset (P=0.021; P=0.018, respectively). Basal and peak levels of gonadotropin hormones were higher in girls, although not statistically significant. In girls, age at puberty onset correlated negatively with standard deviation of body mass index (P=0.023), while age at first consultation correlated positively with bone age (P&lt;0.001), and was associated with younger ages at Gonadotropin-Releasing Hormone stimulation test (P=0.020).Conclusion − This study provides innovative and relevant findings that enhance understanding of CPP presentation according to age, thereby improving clinical management of this condition.

Healthcare Utilization Among Youth with Chronic Illness Receiving Care at a Large Urban Academic Healthcare System.

We sought to understand healthcare utilization and barriers to care among youth with chronic illness who interact frequently with the healthcare system. This was a retrospective analysis of healthcare utilization for youth ≤25 years of age with chronic illness during one calendar year (1 January 2021-31 December 2021) in a single urban academic healthcare system. Inclusion criteria were (1) having at least one healthcare encounter in the calendar year of 2021 and (2) having at least six healthcare encounters over the preceding 3-year period or having a qualifying chronic illness. Demographic and clinical characteristics were collected along with self-reported and derived social determinants of health. Univariable and multivariable regression models were created to identify predictors of missed clinic visits, telehealth use, and activated patient portal accounts. The cohort (N = 14,245) was demographically, clinically, and socioeconomically diverse. The youth had frequent clinic visits (median 9, IQR 4-18), multiple subspecialty care referrals (median 4, 1-8), were prescribed multiple medications (median 6, 3-10), and a high proportion received emergency department (18%) or inpatient treatment (15%). Race and public insurance were significant predictors of missed clinic visits and telehealth use. Primary language was a significant predictor of patient portal activation. Youth with chronic illness who are high users of the healthcare system face a high burden of clinic, emergency room, and hospital visits, referrals, and medications. Systematic efforts to lower the healthcare burden and improve care access should address existing racial and socioeconomic disparities affecting this patient population, who are likely to need frequent healthcare over their lifetime.

069. Evaluation Quality of Life in Colorectal Cancer Patients After Rectal Resection with Ileostomy

Background: Colorectal cancer where each person has a risk of 1:23 of colorectal and increases according to lifestyle colorectal is the 3rd highest cancer with a prediction of 3.2 billion new cases by 2040. Surgery in the form of resection with ileostomy is performed in up to 95% of cases of colorectal cancer. Quality of life after surgery with ileostomy can be evaluation with EORTC QLQ-C30 and CR29. Methods: Retrospective method with total sampling for 1 year 2023-2024 conducted at Sardjito Hospital, patient data obtained from medical records, questionnaire evaluation using interviews with inclusion criteria. Results: There were first complaints the patient in the form of 54% of bloody stools with the time of complaints range 6 months to 1 year. While 60% of patients came from hospital referrals using government health insurance. The age range is 58 years and dominated by women with BMI status of underweight patients and low education. Tumor borders at 5-10 cm from the anal verse with 75% performed adjuvant chemotherapy and 87% performed colonoscopy. Stage was predominantly stage 3 and adenocarcinoma cancer type up to 65%. EORTC QLQ-C30 and EORTC QLQ-CR29 evaluation results showed differences in emotional functioning at 6 months (p0.04) and decreased body image at 3 months postoperatively (p0.02). There were differences in global quality of life in parts but none in general (p&gt;0.05). Conclusion: Overall, patients experience changes in emotional function at 6 months post and body image at 3 months postoperatively. overall global quality of life scores are no significant.

Association of Geographic Social Vulnerability with Race-Based Differences in the Utilization of Total Hip Arthroplasty Surgeries for Medicare Beneficiaries

BackgroundRacial disparities exist in the utilization of total hip arthroplasties (THAs). The social vulnerability index (SVI), which measures geographic-level disadvantage and includes themes such as socioeconomic status, minority status, and language, may partially explain disparities in THA use. Our objectives were to determine the association of the composite SVI with THA use for (i) White Medicare beneficiaries, (ii) Black Medicare beneficiaries, and (iii) the difference in THA use between White and Black beneficiaries. We also determined the association of SVI themes with these THA-use endpoints. MethodsWe used 2013 to 2019 Medicare data to calculate age- and sex-standardized THA use rates for 306 Hospital Referral Regions (HRRs). We estimated multivariable linear regression models to determine the association of the composite SVI and its four themes with THA utilization and with differences in use rates. ResultsLiving in HRRs with the highest SVI (most vulnerable, quartile 4) was associated with lower hip arthroplasty rates for both White and Black beneficiaries (e.g., quartile 4 for White beneficiaries: -0.9, 95% confidence interval [95% CI]: -1.2 to -0.7, P < 0.001; quartile 4 for Black beneficiaries: -0.9, 95% CI: -1.3 to -0.5, P < 0.001) compared to beneficiaries in the least vulnerable HRRs (quartile 1). Higher vulnerability in minority status and language (theme 3) was associated with lower THA utilization for Black beneficiaries only (e.g., quartile 4 for Black beneficiaries: -0.9, 95% CI: -1.2 to -0.5, P < 0.001) and was associated with widening of the White–Black difference in THA utilization (e.g., quartile 4: 0.7, 95% CI: 0.3 to 1.1, P < 0.001). ConclusionHigher composite SVI is associated with lower THA utilization for both White and Black beneficiaries. Higher vulnerability in minority status and language is associated with the widening of the disparity in THA rates. Our findings highlight important mechanisms that need to be addressed to ensure equity in THA access.

Retrospective Investigation of the Utility of Potassium Hydroxide Smear in the Diagnosis and Management of Cutaneous Fungal Infections by Dermatologists

Abstract Background: Superficial cutaneous fungal infections are common dermatologic conditions. A significant proportion do not present with typical clinical findings. However, the 10% potassium hydroxide (KOH) smear, a simple bedside test, is often underused when diagnosing cutaneous fungal infections. Aims: We aimed to evaluate whether KOH smear results altered dermatologists’ diagnosis and management, and the factors that influenced its ability to detect cutaneous fungal infections. Methods: A total of 373 patients with suspected cutaneous fungal infection were identified retrospectively from the dermatology database of inpatient referrals in a Singapore tertiary hospital between 1 January 2017 and 30 June 2020. The dermatologists’ eventual diagnoses, based on their assessment until 2 months post-discharge to allow consideration of KOH smear results and response to treatment, were taken as a gold standard. Statistical analyses evaluated for changes between initial and eventual diagnoses and management relative to the KOH smear. Use of topical steroids, topical and/or systemic antifungals before skin sampling, and whether sampling was done by dermatologically-trained personnel, were assessed for association with KOH smear positivity in eventually diagnosed cases. Results: The percentage of uncertain diagnoses was reduced, and the use of topical antifungal as the sole treatment significantly changed after the KOH smear result was available. The adjusted odds ratio of a positive KOH smear in eventually diagnosed cases was 0.19 when systemic antifungals were used before skin sampling, and 3.03 if sampling was performed by a dermatologically-trained person. Limitations: Limitations of our study include dependence on retrospective medical records which may result in misclassification bias and the limited generalisability of our results to patients managed by non-dermatologists. Conclusions: KOH smear is a useful adjunct in diagnosing and managing cutaneous fungal infections. Clinicians should consider the presence of confounders affecting KOH smears when making an overall clinical diagnosis. Focused training of personnel on skin sample collection may improve the detection rate of KOH smear.

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

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

Comparison of Different Prognostic Scoring Systems in Predicting the Severity and Outcome in Alcoholic Hepatitis in Indian Patients

Abstract Introduction: Alcohol abuse causes a variety of liver diseases including alcoholic steatosis, alcoholic hepatitis (AH), liver fibrosis, cirrhosis, and hepatocellular carcinoma. AH is a clinical syndrome which typically occurs after the harmful use of alcohol. There are mild forms that are likely to improve with conservative management, whereas severe cases are associated with a high mortality rate and have a high risk of death despite treatment. The identification of severe AH is important, as this can be associated with 30%–50% short-term mortality. Existing prognostic scores have been validated in the western population, and the data of application in the Indian population are scant. Materials and Methods: It is a prospective observational study conducted for 2 years at Tertiary Care Hospital Army Hospital (Research and Referral) Delhi. The sample size was kept to be 45. For each patient, clinical and laboratory values were obtained on the day of admission and used to calculate the prognostic models according to their formulas. The various scores – Maddrey’s discriminant function (mDF), Glasgow AH score (GAHS), age, bilirubin, international normalized ratio (INR), creatinine score, and model of end-stage liver disease (MELD) including its modification MELD-sodium were calculated. For patients started on steroids, early changes in bilirubin level and Lille score were calculated. Results: All the prognostic scores were found to be good predictors of mortality. When compared with each other, MELD was most indicative of mortality with maximum area under the receiver operating characteristic curve. All the scores were significantly higher in the nonsurvivors than the survivors (P &lt; 0.0001). Conclusion: AH is a clinical syndrome that occurs after the harmful use of alcohol and confers a high mortality. Effective treatment and support for patients with AH is dependent on a proper assessment of the disease severity and estimation of the risk of death as early in the course of the disease as possible.

Development and Evaluation of Pediatric Acute Care Hospital Referral Regions in Eight States

To develop a set of pediatric acute care hospital referral regions for use in studying pediatric acute care delivery and test their utility relative to other regional systems. We used state-level administrative databases capturing all pediatric acute care in 8 states to construct novel referral regions. We first constructed pediatric hospital service areas (PHSAs) based on 5 837 464 pediatric emergency department encounters. We then aggregated these PHSAs to pediatric hospital referral regions (PHRRs) based on 344 440 pediatric hospitalizations. Finally, we used 3 measures of spatial accuracy (localization index, market share index, and net patient flow) to compare this novel region system with the Dartmouth Atlas, designed originally to study adult specialty care, and the Pittsburgh Atlas, designed originally to study adult acute care. The development procedure resulted in 717 novel PHSAs, which were then aggregated to 55 PHRRs across the included states. Relative to hospital referral regions in the Dartmouth and Pittsburgh Atlases, PHRRs were fewer in number and larger in area and population. PHRRs more accurately captured patterns of pediatric hospitalizations, (eg, mean localization index: 69.1 out of 100, compared with a mean of 58.1 for the Dartmouth Atlas and 62.4 for the Pittsburgh Atlas). The use of regional definitions designed specifically to study pediatric acute care better captures contemporary pediatric acute care delivery than the use of existing regional definitions. Future work should extend these definitions to all US states to enable national analyses of pediatric acute care delivery.

The Fragmentation of Specialty Care. The Role of Referral Location, Type of Referral, and Demographic Factors in Determining Completion Rates for Uninsured Patients in a Student-Run Free Clinic.

Little is known about how location of specialty care affects accessibility for uninsured patients at free clinics. To address this gap, the specialty referral completion rate by location and role of demographic and referral-specific factors were analyzed at an urban-based free clinic. A retrospective review was performed at a single site, student-run free clinic exclusively serving uninsured patients. Referral completion rate and predictors of referral completion were examined including age, race, ethnicity, sex, referral type, and location of referral. Significant predictors (p < 0.05) were included in the adjusted model if the associated odds ratio (OR) was meaningful. A total of 351 referrals met criteria. Completion rate was 53.6%. Co-location of specialty services was associated with a higher completion rate (64.7%, p < 0.001) and counseling referral type had a lower completion rate (11.5%, p < 0.001). Significant predictors of referral completion included sex, ethnicity, location of referral, and referral type (p < 0.001). Hispanic patients had higher rates of completion (68.4%, p < 0.001). On multivariable analysis, non-co-located fee-for-service hospital referrals had lower odds of completion when compared to co-located referrals at the free clinic (OR = 0.25, CI 95% [0.12-0.54], p < 0.001). Also, when compared to other types of referrals, counseling referrals had a 25 times lower odds of referral completion (p < 0.001). There was a higher completion rate of co-located referrals suggesting that multiple locations and health systems may deter patients from seeking necessary care. The lower rate of counseling referral completion indicates that additional efforts are needed to make these services more accessible to uninsured patients.

Evolution of overall survival (OS) after curative-intent lung cancer surgery in a population-based Mississippi Delta cohort.

278 Background: Surgical resection is the most important curative modality for patients with lung cancer, with long-term OS influenced by both surgical quality and cancer biology. We compared surgical care and outcomes over 4 eras in the population-based Mid-South Quality of Surgical Resection (MS-QSR) cohort, an ongoing regional surgical and pathologic quality improvement (QI) dissemination and implementation project. Methods: We implemented a surgical lymph node collection kit and a novel pathology gross dissection method across 12 hospitals encompassing &gt;95% of lung cancer resections in 5 contiguous Dartmouth Hospital Referral Regions. We analyzed the MS-QSR cohort at 5-year intervals characterized by stepped-wedge implementation of specific QI interventions: Era 1 (2004-2008; baseline, no QI), Era 2 (2009-2013; quality feedback, surgical QI pilot), Era 3 (2014-2018; surgical QI implementation), and Era 4 (2019-2023; combined surgical QI and pathology QI implementation). We used standard statistical methods to compare surgical quality; Kaplan-Meier plot, log-rank test, and Cox proportional hazards model with Era 1 as reference to compare OS across eras. Results: Of 7240 resections, 14%, 31%, 29%, and 26% were performed in Eras 1-4, respectively (Table). Attainment of the stringent International Association for the Study of Lung Cancer (IASLC) definition of complete resection increased from 0% in Era 1 to 32% in Era 4; attainment of the American College of Surgeons Operative Standard 5.8 (ACS_OS 5.8), the current US definition of surgical quality, improved from 4% in Era 1 to 67% in Era 4; 120-day mortality rate decreased from 10% to 4% (p&lt;0.0001 for all comparisons). With median follow-up of 4.7, 5.5, 5.6, and 2 years for Eras 1-4, 3-year OS rates were 60%, 64%, 70%, and 79%; 5-year OS rates were 48%, 52%, 58%, and 70%, respectively (p&lt;0.0001). The Hazard Ratio (HR) for mortality decreased from 0.91 (95% CI: 0.8-0.99) in Era 2 to 0.49 (95% CI: 0.43-0.56) in Era 4. Conclusions: Surgical quality and OS sequentially improved in this diverse, high-risk population-based Mississippi Delta surgical resection cohort. We are evaluating the full range of factors associated with this striking OS improvement. Ongoing work is exploring biologic correlates to this improvement. Variable Era 1 N= 988 Era 2 N=2235 Era 3 N=2107 Era 4 N=1910 Median age (Q1, Q3) 68 (62, 74) 68 (62, 74) 68 (61, 74) 68 (61, 74) Male sex (%) 514 (52%) 1234 (55%) 1082 (51%) 977 (51%) Black race 221 (22%) 416 (19%) 450 (21%) 451 (24%) Attained ACS_OS 5.8 40 (4%) 533 (24%) 1050 (50%) 1272 (67%) IASLC complete resectionUncertain completeness 0 (0%)930 (94%) 194 (9%)1932 (86%) 435 (21%)1594 (76%) 606 (32%)1227 (64%) 120-day mortality 100 (10%) 197 (9%) 139 (7%) 72 (4%) 5-year OS 48 (45-51) 52 (50-55) 58 (56-60) 70 (66-74) HR (95% CI) Reference 0.91 (0.83-0.99) 0.75 (0.69-0.83) 0.49 (0.43-0.56)

Unintentional poisoning in older Australians: a retrospective audit of New South Wales Poisons Information Centre data

Introduction Poisons information centres provide phone-based risk assessment and management advice on poisonings. Unintentional poisonings are a common reason for consulting a poisons information centre, and older adults are at increased risk of unintentional poisoning and adverse outcomes. We describe patterns of unintentional poisoning in older adults reported to a regional poisons information centre. Methods We conducted a retrospective audit of poisons information centre call records and identified unintentional poisonings involving older adults (≥75 years) over a 12-month period to determine patient demographics and poisoning circumstances (substances, contributing factors, and disposition recommendation). Univariate analyses identified variables associated with hospital referral and multivariate models to identify independent risk factors in home-dwelling older adults. Results We identified 2,757 calls. More exposures occurred in women (62%) and involved therapeutic errors (70.8%). Paracetamol was the most common drug involved (11%), and cardiovascular drugs were the most common drug class (36%). Only 14.3% of the study population was referred to hospital. Independent risk factors for hospital referral in home-dwelling older adults were exposure to cardiovascular, centrally acting and antihyperglycaemics, non-oral route of administration and symptoms at the time of the call. Discussion Unintentional poisoning is not uncommon, and our findings are similar to those in other countries over recent decades. These findings suggest that unintentional poisoning in older adults is inadequately addressed by current medication safety strategies. Our findings indicate the value of timely advice by poisons information centres for preventing potentially unnecessary hospitalizations. Conclusion Further research is needed to identify more effective approaches to medication safety strategies for older adults. Poisons information centre data contribute to pharmacovigilance activities and could inform patient care.

Enhancing Telemedicine Communication for Improved Outpatient Pediatric Trauma Care.

Pediatric traumatology is a complex field that requires a comprehensive understanding of physeal development, remodeling potential, and the ossification process in order to ensure appropriate patient treatment. The objective of this study was to assess the willingness of practicing physicians to participate in a telemedicine collaboration aimed at enhancing the exchange between the outpatient and inpatient sectors and promoting the digitalization of the pediatric sector. This is in response to the growing significance of digitalization in the medical field. A survey consisting of 15 items was sent to 800 practicing trauma surgeons, pediatric surgeons, and pediatricians within a 100 km radius of Hamburg, Germany. The survey included questions about the respondents' professional experience and telemedicine experience, as well as inquiries about possible telemedicine collaborations. The response rate was 19.3%. Less than half of the participants already used telemedicine in daily practice. In general, 75% of respondents expressed an interest in collaborating with the inpatient sector. The most common reasons for hospital referral were the need for surgery, inadequate treatment of children in practice and co-assessment. The majority were in favor of flexible communication, either via video telephony, imaging applications like or messaging applications. The study revealed a high level of interest in telemedicine collaboration. Information exchange should be tailored to individual needs, with practitioners requiring a versatile and personalized approach that includes imaging. Strict enforcement of data protection regulations is essential. Further research is needed to evaluate the effectiveness of telemedicine collaboration in the treatment of pediatric trauma in both hospital and outpatient settings.

Comparison of quality-adjusted life years (QALYs) of end-stage patients with gastrointestinal cancers receiving conventional therapies with recipients of supportive-palliative care package.

This study aimed to compare the quality-adjusted life years (QALYs) of patients with gastrointestinal (GI) cancer after receiving palliative and supportive care. Conducted at Firoozgar Hospital in Tehran, Iran, this observational study included 500 end-stage gastrointestinal cancer patients. The study divided these patients into two groups: 250 utilized palliative medicine services, while the remaining 250 did not. The study compared the conditions of patients in both groups. Among those receiving palliative care, only 21% underwent chemotherapy, significantly lower than the 55% in the non-palliative care group (P < 0.001). Hospital mortality rates were considerably reduced in the palliative care group, with 115 patients (46%) compared to 200 patients (80%) in the non-palliative group (P < 0.001). The average hospital stay for patients receiving palliative care was 25.11 ± 5.12 days, significantly shorter than the 96.42 ± 14.15 days in the non-palliative group (P < 0.001). The EuroQol 5-Dimensions 3-Levels (EQ-5D-3L) questionnaire scores showed that patients in the palliative care group experienced significantly better outcomes in pain and mood symptoms, but no significant difference was observed in physical function compared to the non-palliative group. Palliative medicine is recommended for gastrointestinal cancer patients as it can significantly reduce unnecessary hospital referrals and length of hospitalization.

Surgical decision-making: key factors influencing the shift from laparoscopic to open cholecystectomy

Background: Recognizing the preoperatively and intraoperatively factors can aid surgeons in making timely decisions to shift from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). This study aims to identify the main factors leading to LC conversion to OC among Iraqi patients. Methods: One-year prospective research was performed using cross-sectional design between 1st April, 2023, and 3oth March, 2024, at Alkalis General Public Hospital and Al Hayat Private Hospital, Diyala, Iraq. Pre and intraoperative data were collected from the planned LC surgeries including demographics, medical history, laboratory and Ultrasound findings. Descriptive and bivariate analysis was carried out to compare variables between patients undergoing LC and those requiring conversion to OC. Results: Out of 172 LC patients (mean age 48.28±12.62), 52.9% were female, 55.8% obese, 50.6% aged 49+, 23.3% diabetic, and 19.8% had emergency cholecystectomy; 15 (8.7%) required conversion to open surgery. The conversion group was mainly men (66.7% vs. 46.5%, P = 0.001) and older (73.3% vs. 48.4% aged 49+, P = 0.003). Obesity (60.0% vs. 55.4%, P = 0.005) and diabetes (53.3% vs. 20.4%, P &lt; 0.001) were more common. Public hospital referrals were higher (86.7% vs. 52.2%, P &lt; 0.001). Elevated total bilirubin, direct bilirubin, and alkaline phosphatase levels were significant predictors of conversion to OC. Adhesions in Calot's triangle (20.0% vs. 13.4%, P = 0.021) were more common in the conversion group, along with unclear anatomy, thick gallbladder wall, bleeding, stone and bile spillage, and cystic duct injury. Conclusion: In conclusion, out of 172 LC patients, 15 (8.7%) required conversion to open surgery, predominantly older men with higher obesity, diabetes, and elevated bilirubin and alkaline phosphatase levels, and more adhesions in Calot's triangle.

Retrospective evaluation of plasma protein tumour markers for early lung cancer detection

BackgroundBlood-based biomarkers might help lung cancer diagnosis. A panel of serum tumour markers (TM) has been validated for hospital referrals due to clinical suspicion of lung cancer. We have compared plasma from a cohort enriched for early-stage lung cancer, including controls from a healthy population cohort.MethodsTM assays for CEA, CYFRA 21-1, CA15.3, ProGRP and SCC were run on a Roche Elecsys 2010 Immunoassay Analyser for a retrospective, nested case-control cohort from the Liverpool Lung Project. The primary endpoints were the sensitivity and specificity of a pre-defined TM panel using published thresholds.ResultsExcept for ProGRP, TM levels were significantly higher in cases and ROC AUC values demonstrated significant discriminant power. Accuracy and levels were higher for late-stage cancers, except for ProGRP which was highest in stage 1 cancers. Although providing similar sensitivity (82.4% vs 88.5%), TMs performed worse for specificity (39.3% vs 82%) and overall (Youden’s Index 0.22 vs 0.77) and this was not improved by threshold optimisation or binary logistic regression.ConclusionsAlthough the TMs were associated with lung cancer status and discriminatory with a high sensitivity when combined, performance was compromised in early-stage disease, which casts some doubt on utility in the screening setting.

Telemedicine as a counselling tool for nurses in Central Africa.

Compare the use and trend of a telemedicine tool for clinical advice among nurses and other Cameroonian healthcare providers and explore its feasibility and accessibility. A comparative observational descriptive study. The sample includes all telemedicine users who request advice from volunteer medical specialists in Spain on clinical cases through the telemedicine tool "diagnosis assistance" (DA). It consisted of a total of 296 Cameroonian health professionals (59% women), of whom 77 were nurses. The variables in which the trend was explored (2013-2022) were DAs entered by nurses versus other healthcare professionals, compared by primary specialty, comments and documents attached. Feasibility and accessibility were explored through an anonymous survey. There were 2527 DAs between 2013 and 2022, of which nurses introduced 68%. There is an increasing trend in the nurse/other healthcare providers ratio, with significant differences in the chi-square of the linear trend between 2015 and 2022 (χ2 = 395.05; df = 7; p < .001). The probability that a DA was requested by nurses (PR >1) was observed in all years except for 2014, 2018 and 2019. The most tele-counselling requested by nurses was in the specialties of internal medicine, obstetrics and gynaecology, and dermatology. The exchange of comments and attachments was mainly conducted among nurses (74.9% and 50.4%, respectively). The users surveyed considered the tool valuable for diagnosis, applicable, with limitations due to cost, Internet quality or lack of time and effective at reducing hospital referrals. Telemedicine for clinical advice has been used mostly and with increasing tendency by nurses, mainly in internal medicine, gynaecology and dermatology, being a useful and feasible resource that can contribute to improving clinical decision-making by African nurses. The study addressed the problem of the shortage of health professionals in Central Africa and the search for alternatives that facilitate decision-making in this context. Tele-counselling tools through digital platforms that put Spanish specialists in contact with health professionals in Central Africa are mostly used by nurses working in rural health centres with a growing trend in their use. The research allows us to determine that tele-counselling tools constitute a well-accepted resource, which has a positive impact in environments with a shortage of human health resources, favouring the safety of both the nursing professional, through support in decision-making, and the populations to whom they provide care, who benefit from a multidisciplinary approach to their processes. The study has adhered to STROBE guidelines. No Patient or Public Contribution.

Hospital referrals, exclusions from hospital care, and deaths among long-term care residents in the Community of Madrid during the March–April 2020 COVID-19 epidemic period: a multivariate time series analysis

BackgroundFrom March 7 to April 7, 2020, the Community of Madrid (CoM), Spain, issued interventions in response to the COVID-19 epidemic, including hospital referral triage protocols for long-term care facility (LTCF) residents (March 18–25). Those with moderate to severe physical disability and cognitive impairment were excluded from hospital referral. This research assesses changes in the association between daily hospital referrals and the deaths of LTCF residents attributable to the triage protocols.MethodsDaily hospital referrals and all-cause mortality from January to June 2020 among LTCF residents and the CoM population aged 65 + were obtained. Significant changes in LTCF resident daily hospital referrals time series, and in-LTCF and in-hospital daily deaths, were examined with tests for breaks and regimes in time series. Multivariate time series analyses were conducted to test changes in the associations between LTCF resident hospital referrals with daily deaths in-hospital and in-LTCF, and in the CoM population aged 65 + when the triage protocols were implemented.ResultsAmong LTCF residents, hospital referrals declined sharply from March 6 to March 23, 2020. Increases in LTCF residents' daily deaths occurred from March 7 to April 1, followed by a decrease reaching pre-epidemic levels after April 28. The daily ratio of in-hospital deaths to in-LTCF deaths reached its lowest values from March 9 to April 19, 2020. The four versions of the triage protocol, published from March 18 to March 25 had no impact on further changes in the association of hospital referrals with daily deaths of LTCF residents in-hospital or in-LTCF.ConclusionsWhile LTCF residents’ deaths increased, hospital referrals of LTCF residents decreased with the introduction of the CoM governmental interventions on March 7. They were implemented before the enactment of the triage protocols, protecting hospitals from collapse while overlooking the need for standards of care within LTCFs. The CoM triage protocols sanctioned the existing restrictions on hospital referrals of LTCF residents.