Increase In Patient Referrals Research Articles

Establishing palliative care in tribal and rural Indian setting: A participatory action research approach.

e24085 Background: We established a palliative care center in the tribal area of Santhal Pargana, India, under a tertiary care facility, as a crucial step in addressing the palliative needs of oncology patients. This study assesses the center's inaugural year, focusing on referral patterns, morphine consumption, and pain management. Methods: Data from all patients visiting the palliative care outpatient department (OPD) in 2023 were prospectively collected and analyzed. The study focused on key palliative care indicators, including morphine consumption, patient referrals, and the mean Numeric Rating Scale (NRS) pain score after initial consultation. The PAR approach was utilized to tailor services to the community's needs. Results: The center observed an increase in patient referrals, from 8 new patients in January to 19 by December. The patient demographic primarily comprised individuals with head and neck cancer (43%), followed by breast cancer (28%) and gall bladder cancer (12%), alongside other types such as cervix, sarcomas, lung, and adult hematolymphoid malignancies. Bone metastasis was present in 46 (55.4%) patients at initial presentation. Morphine consumption demonstrated a notable rise, from 840 mg in May to 2860 mg in December, totaling 9800 mg for the year. The mean NRS pain score improved significantly from 6.5 in January to 4.3 post-initial consultation. The center maintained an overall median of 3 consultations per patient, and bereavement support was provided to 13 (15.7%) patients. Conclusions: The integration of the Participatory Action Research approach, specifically the CTC-5, was instrumental in the successful initiation and expansion of palliative care services within the center. The structured training, mentorship, and organizational restructuring, facilitated by the program, were crucial in establishing a modest palliative care infrastructure. This comprehensive approach not only enhanced care delivery but also ensured the sustainability and adaptability of palliative services, effectively addressing the gap in palliative care in rural, tribal settings.

Improved Detection of Fibrotic Nonalcoholic Fatty Liver Disease in Community-Based Referrals.

Background: Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease with increasing rates globally. Patients with type 2 diabetes mellitus have higher risk of developing NAFLD. Patients with a higher degree of liver fibrosis in NAFLD are at an increased risk for liver-related mortality, but get missed easily during the referral process. This project aims to improve early detection and linkage-to-care of fibrotic NAFLD patients. Methods: We utilized a combination of automated electronic health record (EHR)-based fibrosis (FIB)-4 score and directed provider education. A health-system wide FIB-4 score calculator that providers can easily add to their workflow for NAFLD patient triaging. Data were analyzed at 6 and 12 months after implementation. Results: Postimplementation, there was an increase in patients referred to hepatology with higher degree of liver fibrosis and decreased referral to hepatology with low risk of liver fibrosis, measured by FIB-4 score. At baseline, ∼55% of referred patient to hepatology had FIB-4 score <1.3 compared to 38% at 12 months postimplementation. There was an increase in referral of patients with FIB-4 scores >1.3 when compared to preinterventions, 62% versus 45%. This is most pronounced in patients with severe fibrotic disease with FIB-4 score >2.67, 30% versus 12%. Conclusions: Automated FIB-4 score in EHR can improve appropriate linkage-to-care for at-risk fibrotic NAFLD, especially when coupled with targeted provider education. The durability of such improvement is essential to study along with the need to increase broad acceptance across health systems.

Heartburn Center Set-Up in a Community Setting: Engineering and Execution.

Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a “center of excellence” (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD.Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery.Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1–11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution.Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.

093 Changing Picture of ATTR Wild Type Cardiomyopathy in Australia – Queensland Amyloidosis Centre Experience

Queensland Amyloidosis Centre was established over 10 years ago to deliver the multidisciplinary specialist services to patients with AL and ATTR amyloidosis. From 2017 we have observed a significant increase in referrals of patients with ATTRwt cardiomyopathy which coincided with the broader implementation of new diagnostic tool (⁹⁹Tc bone scintigraphy). We present an epidemiological and clinical data on our cohort with confirmed wild type TTR cardiac deposition. We analysed the group according to the year of referral (before vs after 2017). Our 103 patients are predominantly male (98 male, 5 female) with median age of 78 years (range, 57- 91). On presentation 42% were in Gilmore stage 1 and 40% had reduced LV ejection fraction (LVEF<50%). The average LV wall thickness (IVS) was 1.7cm and global longitudinal strain GLS (-12.8%). The observed 2 years mortality was 23%. The introduction of ⁹⁹Tc-DPD bone scintigraphy resulted in a shift to a non-biopsy pathway for diagnosis of ATTR cardiomyopathy. Positive ⁹⁹Tc-DPD scan (Perugini grade 2 and 3) obviated the need for tissue (cardiac) biopsy in majority of cases. We observed a reduction in natriuretic peptides levels, LV wall thickness and improvement in LV ejection fraction, GLS and clinical stage in patients referred after 2017. We also noted a change in 2-year survival: 69% (before 2017) vs 81% (after 2017). The early recognition of the disease due to an increased clinicians’ awareness and the advances in diagnostic workup are changing the clinical landscape of ATTR cardiomyopathy in Australia.Table 1Characteristics of 103 patients with ATTRwt cardiomyopathy ∼ year of referral, mode of dgn: ⁹⁹Tc- DPD bone scintigraphy (Dgn⁹⁹Tc) vs biopsy (DgnTiss), interventricular wall thickness (IVS), LV ejection fraction (EF), Global Longitudinal Strain (GLS), average BNP, NT-proBNP levels, %Gilmore Stage 1 (NT- proBNP<3000ng/l or BNP<400ng/l and eGFR>45ml/min) and survival at 2 years.Year/NoPatientsDgn⁹⁹TcDgnTissIVS cmEF%GLS%BNP ng/lNT-pBNP ng/lGilmoreStage 1Survival2 yearPre 173627%1173%251.849-10580732440%69%Post 176770%4930%181.656-16463292643%81% Open table in a new tab

Effectiveness of Interventions to Decrease Image Ordering for Low Back Pain Presentations in the Emergency Department: A Systematic Review.

Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients. A protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third-party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed. The search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and postintervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percentage change in imaging in a specific image modality (22.7%-47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography. While imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher-quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population.

Transplant Professionals' Perceptions of Long-Term Care Residents' Candidacy for Kidney Transplantation.

Given the aging end-stage renal disease (ESRD) population, kidney transplant (KTx) centers may experience an increase in referrals of patients living in long-term care (LTC) settings (eg, skilled nursing facilities, assisted living facilities, group homes, and boarding homes). To identify best practices among KTx professionals when considering individuals in LTC settings for transplantation. A cross-sectional survey administered online to US transplant professionals via e-mail LISTSERVs and other professional networks. One hundred twenty-six KTx professionals working in the United States. The survey was composed of demographic questions and 6 hypothetical scenarios. These scenarios asked participants to assess transplant candidacy of patients with ESRD living in LTC settings based on the information provided in the scenario. Each scenario presented a different variable that necessitated LTC placement, including lack of social support, moderate intellectual disability, stable neurological condition, mild dementia, a psychiatric condition controlled on medications, and limited mobility. The only scenario that elicited an overwhelmingly negative response was mild dementia with 73.9% of participants unwilling to consider such patients for KTx. By contrast, the proportion of KTx professionals reluctant to proceed with KTx in the remaining scenarios ranged between 40.0% and 50.6%. This survey of a large number of KTx professionals suggests that there is presently no best practice consensus regarding offering KTx to patients living in LTC settings. Further research should include a broader range of KTx professionals and should also include a study of outcomes with KTx in this particular patient population.

Use of Palliative Care Services in a Tertiary Cancer Center.

Despite increasing prevalence of palliative care (PC) services in cancer centers, most referrals to the service occur exceedingly late in the illness trajectory. Over the years, we have made several attempts to promote earlier patient access to our PC program, such as changing the name of our service from PC to supportive care (SC). This study was conducted to determine the use of PC/SC service over the past 8 years. We reviewed billing data for all PC/SC encounters. We examined five metrics for use: inpatient consultations as a percentage of hospital admissions, ratio of inpatient consultations to average number of operational beds, time from hospital registration to outpatient consultation, time from advanced cancer diagnosis to consultation, and time from first outpatient consultation to death/last follow-up. Over the years, we found a consistent increase in patient referrals to the PC/SC program. In the inpatient setting, we found approximate doubling of the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds (from 10% to 19% and from 2.4 to 4.9, respectively; p < .001). In the outpatient setting, we observed variations in referral pattern between oncology services, but, overall, the time from consultation to death/last follow-up increased from 4.8 months to 7.9 months (p = .001), which was accompanied by a significant decrease in the interval to consultation from hospital registration and advanced cancer diagnosis (p < .001). We have observed a consistent annual increase in new patient referrals as well as earlier access for outpatient referrals to our SC service, supporting increased use of palliative care at our cancer center. In response to accumulating evidence on the benefits of palliative care (PC) referral to oncology patients, efforts are being made to increase PC use. This study, conducted at MD Anderson Cancer Center, demonstrates consistent annual growth in PC referrals, which was accompanied by a significant increase in the outpatient referral of patients with nonadvanced cancer and earlier referral of those with advanced cancer. However, significant variations in the referral patterns between oncology services were observed. These results have implications for other cancer centers looking to enhance use of PC services by having a business model that allows for appropriate space and staff expansion.

Medium-term cost-effectiveness of an automated non-invasive ventilation outpatient set-up versus a standard fixed level non-invasive ventilation inpatient set-up in obese patients with chronic respiratory failure: a protocol description

IntroductionObesity is an escalating issue, with an accompanying increase in referrals of patients with obesity-related respiratory failure. Currently, these patients are electively admitted to hospital for initiation of non-invasive ventilation...

The power of the atom

e-mail: kkrohn@uw.edu challenge of carbon-11’s very short half-life was resolved when carbon-14 became available, and Melvin Calvin’s group worked out carbon metabolism pathways as they appear in textbooks today. The use of radioisotopes in human research has always been controversial. Creager is deft at taking the reader from human experiments that could now be considered ethically suspect to Nobel Prize–winning research. For example, the collaboration between military interests and biomedical research led to studies of radioisotopes for therapy, including some of the radiolabeled antibodies that are now used for cancer therapy, and also eventually led to peer review of human experimentation. Creager discusses the use of radioisotope beams for radiation therapy. Large quantities of cobalt-60 and cesium-137 were available from reactors, and General Electric designed a housing to contain them for delivering beam radiation. Treating cancer with radioisotope beams was politically expedient and led to a large increase in patient referrals to sites that had the equipment. Government officials were concerned about the impact of effluents and radioactive waste. One study used phosphorus-32–containing phosphate in a pond to measure the cycling of phosphorus and showed that plants from the pond contained 1,000-fold more radioactivity than an equivalent amount of water. Other studies asked whether the volume of freshwater needed to cool reactors would introduce heat, toxins and radioactivity into the water that could harm fish in neighboring rivers. Plankton accumulate radioactivity and introduce radioisotopes into the food chain. Also, radioactivity could be released into the air and accumulate in birds, mammals, reptiles and insects. The impact of nuclear reactors on their environment has had a lasting negative impact that is still argued today. Creager ends the book by providing her perspective on the history and future of atomic science. I had the most trouble with this section because the author presented the government’s role as mostly related to nuclear power and weapons. Clearly, the government was excessively exuberant about nuclear power, but its dual role in regulating and promoting the industry did not work, and by the time these functions were separated, public opposition had gathered force. Accidents such as Three Mile Island and Chernobyl increased public skepticism of nuclear power, probably more than is deserved. Government and industry clearly share blame for the poor reputation of nuclear power. But society and the political world also carry responsibility. We need to motivate industry and scientists to solve the problem of safe care of radioisotope waste and to appreciate that nuclear power could still be an important source of clean green energy. Medical applications of radioisotopes followed what Creager calls “a strikingly different trajectory,” becoming routine in research and therapy independent of the backlash against nuclear power. But she suggests that there will be a limit to radioisotopes as scientific and medical tools, in large part due to the burden of regulation and the radioactive waste disposal problem. Fluorescent tags can sometimes replace radioisotope tags, and it is unclear whether aging reactors can sustain the demand for radioisotopes. Nevertheless, I am optimistic that the use of radioisotopes will increase due to their value in unraveling the secrets of our natural world.

Pharmacy-based immunizations growing, improving

Using an ever-increasing network of patient-referral relationships and taking steps to improve documentation practices, pharmacists are increasing the volume and diversity of immunization services they offer in the pharmacies of America, according to a 2013 survey conducted by APhA. Using an ever-increasing network of patient-referral relationships and taking steps to improve documentation practices, pharmacists are increasing the volume and diversity of immunization services they offer in the pharmacies of America, according to a 2013 survey conducted by APhA. The national survey assessed pharmacy-based immunizations on behalf of the U.S. Department of Health & Human Services National Vaccine Program Office. Links to the Internet-based survey were e-mailed to 32,603 pharmacists in all pharmacy practice settings from August 24 to September 14, 2013, and 2,351 pharmacists responded. Overall, 77% of pharmacy practice sites were offering vaccinations on a walk-in basis without an appointment. Compared with 2012 survey results, the use of appointment-based or time-restricted access decreased, with only 36% of practice sites in 2013 offering vaccinations by appointment, compared with 41% in 2012. In addition, immunization services offered via instore clinics remained low, with 18% of respondents selecting this option, down from 26% in 2012. Influenza remained the most commonly administered vaccine (88%). However, the majority of practice sites also reported the current administration of pneumococcal (77%), herpes zoster (75%), and tetanus (57%) vaccines. Fewer than one-half of the practice sites were reported as currently administering vaccines for hepatitis B (47%), hepatitis A (43%), meningococci (43%), human papillomavirus (37%), international travel (25%), and pediatric patients (10%). The percentage of currently administered vaccines was higher for most categories compared with results of the 2012 survey (e.g., herpes zoster vaccine administration was 57% in 2012). To successfully expand immunization services beyond influenza, pharmacists ranked their highest priorities (on a 10-point scale) as obtaining the support of public health (7.02), pharmacy management (6.35), and medicine (6.32). Other priorities included training pharmacists on how to counsel patients or offer additional vaccinations (6.25), and aligning or including incentives in performance evaluations of immunizing pharmacists (6.19). More than one-half of pharmacies administer influenza, pneumococcal, zoster, or tetanus vaccines. The National Vaccine Advisory Committee's (NVAC) updated Standards for Adult Immunization Practice support the establishment of patient referral relationships to minimize any potential patient barriers to vaccination (see related article on page 66). The 2013 results show that referrals are happening across various groups. Pharmacists reported an increase in patient referrals from physicians (88% vs. 84% in 2012) as a result of various factors, including vaccine availability, cost, reimbursement, and time. In addition, 29% of responding pharmacists reported referring patients to physician offices to address immunization issues. Among all practice sites, 22% of respondents were referring patients to other immunizing pharmacists when access was not available at their primary pharmacy practice site. The majority of respondents (56%) reported that other pharmacists had referred patients to them, and 16% of practice sites noted referring patients to their own in-store clinic practitioner. Nearly one-quarter of respondents (24%) had referred patients to the public health department. Respondents practicing in independent pharmacies (32%) were most likely to make such referrals. One in 10 practice sites (9%) reported that their immunizing pharmacists have protocols or standing orders with the public health department. Another important component of the updated NVAC standards is appropriate documentation that takes advantage of electronic medical records and state immunization registries. The survey noted that 91% of respondents' practice sites maintain documentation of a patient receiving a vaccination in the pharmacy, 69% provide patients with a copy of their consent form, and 53% enter the vaccination into the patient's medical record. In addition, more than 6 in 10 respondents (64%) were providing documentation of the patient's vaccinations directly to the patient's physician. Overall, 35% of respondents were entering a patient's vaccinations into an immunization registry, and 28% noted submitting all immunizations to state or local immunization registries. Only a small percentage of respondents reported submitting adult (7%), childhood (6%), adolescent (5%), and influenza (5%) immunizations to state or local registries; 11% said they were not permitted to access state and local immunization registries. The results of APhA's 2013 immunization survey show the increased administration of numerous vaccines by pharmacists, a growing network of patient referral relationships, and steps being taken toward improved documentation practices. Additional improvements can be made in the coming years by focusing on initiatives that improve immunization access and use of immunization registries.

Provider-initiated HIV testing increases access of patients with HIV-associated tuberculosis to antiretroviral treatment

Timely initiation of antiretroviral treatment (ART) is a critical component of the case management of patients with HIV-associated tuberculosis (TB) and advanced immunodeficiency. We sought to determine the impact of the introduction of provider-initiated HIV-testing in TB clinics in 2005 on subsequent referrals of patients with HIV-associated TB at a community-based ART service in Cape Town. Retrospective analysis of an ART cohort database (2002 - 2008) stratified by calendar periods. Between 2002 and 2008, 3 770 ART-naive adults enrolled in the ART service. Overall, 27.4% of these patients had been referred from TB clinics with a diagnosis of HIV-associated TB. This proportion increased from 16.0% of referrals in the period 2002 - 2005 prior to the introduction of provider-initiated HIV testing, to 34.7% in 2007 - 2008 (p<0.001). The median duration of TB treatment completed prior to referral decreased from 3 months to 1 month (p<0.001) and patients enrolled with higher median CD4 cell counts (71 cells/microl v. 95 cells/microl; p<0.001). Moreover, the proportion with recurrent TB epiSodes decreased from 8.6% to 3.2% (p<0.001). Introduction of provider-initiated HIV testing by the TB control programme was temporally associated with a major increase in referrals of patients with HIV-associated TB to this ART service, a progressive decline in referral delay, improvements in baseline CD4 cell counts, and fewer recurrent TB episodes. Such trends are likely to be associated with improved survival, and these data strongly support this HIV-testing strategy.

Pulmonary Venous Hypertension: A Pulmonologist's Perspective

Increased pulmonary hypertension (PH) awareness in the general public and among health providers has led to an increase in referral of patients who are found to have elevated estimates of pulmonary artery systolic pressure (PASP) on a transthoracic echocardiogram (TTE), without other strong features suggestive of precapillary PH (pulmonary arterial hypertension; PAH). Some of these patients undergo TTE as part of their workup for unexplained dyspnea that appears out of proportion to their other comorbidities. Many of these patients are older individuals with underlying conditions such as systemic hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), and obstructive sleep apnea (OSA). While some of them may have PAH, accumulated experience in the PH community suggests that many of these patients will be ultimately found to have elevated left ventricular (LV) filling pressures and impaired LV relaxation as the cause of their dyspnea and elevation of pulmonary pressures on TTE.12 These findings are consistent with a form of Group 2 PH termed LV diastolic dysfunction, more recently termed heart failure with preserved left ventricular systolic function (HFpEF) (Table 1).2 Other forms of Group 2 PH, defined as “pulmonary hypertension owing to left-sided heart disease,” include LV systolic dysfunction or left-sided valvular disease.2 For the purpose of this article, the term pulmonary venous hypertension (PVH) will be used to refer to Group 2 PH, HFpEF. Being able to accurately discriminate PAH (precapillary; Group 1 PH) from PVH (postcapillary; Group 2 PH) is critical to determine and apply the appropriate treatment course. This is a difficult, yet frequently encountered clinical dilemma, which can fall into a “gray zone” with respect to clinical classification. We will provide important clinical features that should heighten the clinician's awareness and suspicion of this rapidly growing phenomenon. These features are critical when trying to differentiate PAH (Group 1 PH) from PVH (Group 2 PH).

Gatekeepers and the Gateway – a Mixed-Methods Inquiry into Practitioners' Referral Behaviour to the Gateway Clinic

The Gateway Clinic is a specialist NHS service in South London providing acupuncture and Chinese medicine. The clinic receives a diverse range of referrals from an expanding population of local general practitioners (GPs). This study explores the referral behaviour of GPs and other primary care users of the Gateway Clinic. A pragmatic mixed-methods approach was used, combining mapping of GPs' usage of the Gateway as taken from the clinic's database between the years 2000 and 2005, a questionnaire survey of the referring primary care practitioners in 2005, and data, including a thematic analysis of the interview transcripts from semi-structured interviews of a purposive sample of those GPs who refer. Doctors in the community refer a wide range of health problems to the Gateway Clinic. The most common referrals were musculoskeletal conditions (38-44%), general and unspecified conditions (11-14%), blood and immune system conditions (6-12%), psychological conditions (8-13%), neurological conditions (6-9%), gynaecological conditions (5-6%) and digestive conditions (5-6%). The health problems referred by local healthcare practitioners correlate strongly with the patient profile seen in private acupuncture practice. Between 2000 and 2005 numbers of healthcare practitioners increased by 218% resulting in a 300% increase in patient referrals made to the clinic; the mean frequency of referral per practitioner increased by 71%. Analysis of the qualitative data suggests that positive clinical experience encourages GPs to increase the range of conditions they refer leading to the development of informal referral guidelines. The Gateway Clinic has become an increasingly popular referral resource. The influences that drive referral to the clinic are multiple and follow "tacit guidelines". GPs select patients on the basis of their individual clinical experience, informed by positive patient feedback and often only after more conventional medical treatment options have been exhausted.

The Quality of Screening Colonoscopies in an Office-Based Endoscopy Clinic

Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures. To compare the quality of office-based screening colonoscopies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications. Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained. A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy. The Ontario Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.

NS01 IS THERE A RESURGENCE OF CEREBRAL REVASCULARIZATION?

Since the publication in 1985 of the EC‐IC bypass study group, which demonstrated failure of EC‐IC bypass surgery to reduce stroke rate, there has been a dramatic reduction in the number of EC/IC bypass surgeries performed globally.However there have been ongoing concerns amongst neurosurgeons that the EC‐IC bypass operation still has a role, at least in selected groups of patients. These groups include, patients with Moya Moya disease, those requiring arterial sacrifice (particularly when trial occlusion demonstrates symptomatic cerebral ischaemia), and in certain patients with cerebral ischaemia in whom medical management has failed and there is a demonstrable reversible ischaemic deficit.Over the past decade there has been de‐skilling of the neurosurgical community in cerebrovascular procedures. Even those neurosurgeons who have maintained a high cerebrovascular case‐load rarely perform EC‐IC bypass surgeries. The technical demands of the procedure are such that it is difficult to maintain skill proficiency with a low case‐load.Nevertheless a few cerebrovascular surgeons at large institutions have recently noted an increase in referral of patients requiring EC‐IC bypass. Current multicentre studies are underway to re‐evaluate its role. It would seem likely that a modest increase in the demand for this surgery will occur.

Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service.

There remains a critical shortage of cadaveric organs. At a large inner city level one trauma centre, several strategies were devised and combined to (a). optimize the physiologic status of potential donors, (b). promote awareness of the donation process among health care professionals and (c). perform quality control on the organ donation system - all in an effort to improve organ donation rates. Resuscitative and maintenance protocols were devised and implemented through a multidisciplinary team approach for patients diagnosed with brain death. We report the effect this approach has had on organ donation in a single centre. A death record review (DRR) by the local organ procurement agency (OPO) was used to identify the number of patients diagnosed with brain death at Los Angeles County Hospital each year from 1995 through 2001. Data were collected to determine the number of these potential donors that eventually underwent organ donation. Data were collected for two time intervals: Phase I (1995-98) and Phase II (1999-2001). During Phase I, there was no focused institutional programme for the approach to potential donors. During Phase II, an institutional programme including the following characteristics was implemented: 1). donor resuscitation protocol, 2). assignment of a dedicated OPO coordinator liaison to interact with families, hospital personnel and the coroner's office, 3). assignment of the primary role of stabilization and care of potential donors and the integration of all medical services to the trauma service, and 4). biweekly conferences to review policies, protocols, and outcomes of donor management strategies. From 1995 to 2001 there was a large increase in patient referrals for donor evaluation from 86 (Phase I) to 124 (Phase II). There was a smaller increase in the number of suitable donors: Phase I (mean: 51/year) and Phase II (mean: 63/year). There was, however, an increase in the mean number of actual organ donors from 14.2/year to 25.7/year from Phase I to Phase II and an increase in organs donated from 29 to 49. Organ donor declines decreased from 53% (Phase I) to 39% (Phase II). Strategies to increase the number of cadaveric organs available for organ transplantation are crucial. A strategy combining prompt identification of potential organ donors, institution of resuscitative protocols, a multidisciplinary team approach, educational activities and utilization of personnel expert in organ procurement led to a marked increase in the number of organ donors and the number of organs donated at a single institution. Wider application of this approach should prove successful in increasing organ donation in a similar fashion in other institutions.

Management of Renal Artery Stenosis: Effects of a Shift from Surgical to Percutaneous Therapy on Indications and Outcomes

The treatment of choice for renal artery occlusive disease has shifted from open repair to percutaneous angioplasty and stenting in many institutions. Whether this change in treatment modality will lead to altered and, perhaps, relaxed indications for intervention is unclear. We reviewed our experience to determine if a shift from open surgery to percutaneous management of renal occlusive disease was associated with changes in either indications for intervention or patient outcomes. Over an 8-year period, 165 patients had intervention for renal artery stenosis by our vascular surgery teaching service. Over the period there was a dramatic increase in interventions per year (4 patients 1994 to 57 patients 2001). There was also a shift from open to endovascular management. Patient demographics and indications for intervention showed no difference between open and endovascular groups. Outcome analysis revealed similar technical success rates between groups but a significantly higher morbidity and mortality rate in the surgical group. A shift from open to percutaneous treatment of renal artery occlusive disease led to a significant increase in patient volume. This increase occurred without a change in patient demographics or indications for therapy, and appeared to reflect an increase in patient referrals.

Mesial Temporal Lobe Epilepsy: What Have We Learned?

Mesial temporal lobe epilepsy is the most common form of human epilepsy, and its pathophysiological substrate is usually hippocampal sclerosis, the most common epileptogenic lesion encountered in patients with epilepsy. The disabling seizures associated with mesial temporal lobe epilepsy are typically resistant to antiepileptic drugs but can be abolished in most patients by surgical treatment. Anteromesial temporal resection, therefore, is the most common surgical procedure performed to treat epilepsy, and stereo-tactically implanted intracerebral electrodes are required in some patients to localize the epileptogenic region. This clinical setting provides a large number of patients for invasive in vivo research with microelectrode and microdialysis techniques and in vitro research following surgical resection on a single epileptic disorder. Consequently, much has now been learned about the fundamental neuronal mechanisms underlying the epileptogenic properties of the human hippocampus in mesial temporal lobe epilepsy. Parallel reiterative studies in patients and animal models of this disorder indicate that enhanced inhibition, in addition to enhanced excitation, underlies the appearance of hypersynchronous neuronal discharges responsible for generating spontaneous seizures. Recent studies have elucidated what may be unique electrophysiological markers of epileptogenicity, which could have valuable diagnostic utility. Although basic research on mesial temporal lobe epilepsy may ultimately suggest novel approaches to treatment and prevention, attention must also be given to maximizing the application of available effective treatments. In particular, the safety and efficacy of surgical therapy has greatly improved in recent years, yet this alternative treatment remains seriously underutilized worldwide. An appropriate increase in referral of patients with this surgically remediable syndrome to epilepsy centers will not only relieve a great many patients of their disabling seizures and reduce the burden of epilepsy but will also provide increased opportunities for invasive research that could ultimately result in even more effective therapies or cures.

Multidrug-resistant tuberculosis: long term follow-up of 40 non-HIV-infected patients.

There has been a steady increase in referrals of patients with multidrug-resistant tuberculosis (MDR-TB) who are human immunodeficiency virus (HIV) negative. Between 1986 and 1999, 40 patients were admitted to the authors' institution, eight of whom were admitted between January and June 1999. The management of such individuals is difficult. Although they are a clinically and epidemiologically important group of patients, few reports detail their management. To review the demographics, clinical management and long term outcome of 40 non-HIV-infected individuals with MDR-TB referred to the only specialized TB inpatient service in Ontario. Clinical hospital records were reviewed. Twenty-one men and 19 women (mean age 41+/-18 years) were admitted between January 1986 and June 1999 with MDR-TB and negative serology for HIV. Thirty-eight patients (95%) were born outside of Canada. Twenty-six patients (65%) had a history of previous TB. All were symptomatic with productive cough and positive sputum smears for acid-fast bacilli. There was a delay of 4.5 months between the initial diagnosis of TB and the recognition of the presence of MDR-TB. Four patients (10%) had TB resistant to isoniazid and rifampin only. Over 50% of patients had TB with additional resistance to streptomycin, and over 40% had additional resistance to ethambutol. Coexisting resistance was also found in significant numbers for pyrazinamide, ethionamide, para-aminosalicylic acid and cycloserine. Bacteriological conversion was achieved in 34 patients (85%). Six patients underwent surgical resection for localized lung disease. Twenty-four patients completed treatment and have remained free of disease for 33+/-25 months. All five patients (12%) who died had longstanding disease before their referral. MDR-TB is most frequently seen among immigrants with a previous history of TB, especially if they come from countries in which TB is highly prevalent. Outcome can be improved by a more timely recognition of MDR-TB.

Industrial therapy organisation 1966?1970

A brief survey of the organisation in the United Kingdom of existing facilities for rehabilitation, training and sheltered employment precedes a description of five years work in a voluntary, non-profit making organisation (Bristol Industrial Therapy Organisation (Bristol) Limited). The classification of patients referred during this period is reported and the outcome of attendance. The success and failure, according to sources of referral and diagnosis, is commented on and a two-year follow-up is given. A summary of outcome for the first eleven years of the Organisation is recorded. — The present state of industrial therapy is discussed and the need for research and for workers in the field to become more highly specialised is stressed. — The change in clientele is noted with an increase in referral of patients suffering from subnormality. A likely increase in persons with personality disorders is anticipated. — The different methods of approach by I. T. O. to the problem of reemployment are enumerated and the applicability of the I. T. O. principle to other groups, for example, ex-prisoners, prisoners, physically handicapped, etc. is suggested. The strength accruing to the Organisation from close links with the hospital and community is noted and the Organisations view that there should not be separate rehabilitation services for the psychiatrically ill and for the physically ill is stated. The continuation of voluntary organisations such as I. T. O. is considered desirable but not in the continuous provision of services which are clearly the responsibility of statutory authorities. These authorities must give fresh thought to the problem of providing services appropriate to modern needs.