Initial Clinic Appointment Research Articles

Assessing the impact of a dedicated referral and management algorithm in maternal hypothyroidism.

The significant risks of hypothyroidism during pregnancy can be mitigated through timely diagnosis and initiation of thyroxine to achieve a maternal euthyroid state. This study aimed to evaluate the efficiency of hospital endocrine services by assessing the rate of thyroxine commencement before the initial clinic appointment, the median gestational age at the first consultation, the rate of guideline-appropriate investigations, perinatal outcomes, and the proportion of referred patients who achieved their target thyroid-stimulating hormone (TSH) levels before and after implementing a dedicated referral and management pathway. A retrospective clinical audit was conducted using electronic medical records for the first fifty consecutive patients with hypothyroidism referred to the hospital clinic during two-time intervals: from April 1 to September 1, 2020 (pre-intervention) and from April 1 to September 1, 2021 (postintervention). Following the pathway implementation, there was no significant difference in the proportion of women with initially raised TSH who were prescribed thyroxine prior to the first clinic appointment (P=0.83). However, the first TSH measurement occurred earlier (median 5.5 vs. 6.5 weeks, P=0.011), and specialist reviews were conducted sooner (median 19 vs. 22 weeks, P=0.032). Significantly more women with elevated TSH underwent thyroid autoantibody testing postintervention (78% vs. 55.5%, P=0.035). There was no significant difference in perinatal outcomes. All women achieved their target TSH levels, with a median final TSH of 1.6 mIU/L (IQR: 1.2 to 2.3). While the proportion of referred patients achieving target TSH levels during pregnancy remained unchanged, certain measures of service efficiency improved. These included earlier TSH measurement, earlier endocrinologist review, and increased detection of thyroid autoantibodies.

Identify, screen and treat via electronic pathway: a semiautomated approach to retriaging a liver clinic waitlist.

Long specialist outpatient waiting lists are a source of clinical risk. Triage assignment is based on subjective assessment of referrals and fails to account for dynamic changes in disease status while patients await clinical review. To pilot an innovative triage method using a trifold approach to conduct noninvasive assessment of fibrosis and to determine the feasibility of reflex hepatitis C virus (HCV) polymerase chain reaction (PCR) testing. A total of 1006 patients awaiting an initial liver clinic appointment at a tertiary Australian hospital were sent a short message service (SMS) requesting a blood test be completed. The first 60 patients received an SMS only, and the subsequent 946 patients also received a phone call from a Liver Care Guide (LCG), a nonclinician employed to increase patient engagement. Liver fibrosis assessment through noninvasive testing was performed using an aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 (FIB4) score. Patients with an APRI ≥1, FIB4 ≥3.25 or positive HCV PCR were retriaged to Category 1. Four hundred ninety (49%) patients completed testing and 40 (4%) were triaged to Category 1. Subanalyses demonstrated increased response rates with LCG input (P = 0.012). Retriaged patients had been on the waitlist for a median of 216 days, exceeding initial category recommendations. This study successfully implemented a semiautomated strategy that prioritises patients with probable advanced liver disease or active HCV, demonstrating enhanced patient engagement with LCG support. It highlights the burden of patients referred for specialist care and the need for innovative strategies for monitoring and objective risk stratification.

Comparison of 30-day retention in treatment among patients referred to opioid use disorder treatment from emergency department and telemedicine settings

IntroductionTelemedicine is a feasible alternative to in-person evaluations for people with opioid use disorder (OUD). The literature on medications for opioid use disorder (MOUD) telemedicine has focused on ongoing OUD treatment. Emergency department (ED) visits are an opportunity to initiate MOUD; however, little is known regarding the outcomes of patients following telemedicine referrals for MOUD from emergency settings. The current study describes rates of initial outpatient clinic appointment attendance and 30-day retention in care among patients referred by telemedicine compared to ED referrals. MethodsThis paper reports a retrospective review of data for patients referred from EDs or telemedicine through the Medication for Addiction Treatment and Electronic Referrals (MATTERS) Network. The MATTERS online platform collects data on patient demographic information (e.g., age, gender, race/ethnicity, and insurance type), reason for visit, prior medical and mental health history, prior OUD treatment history, and past 30-day substance use behaviors. Analyses compared initial visit attendance and 30-day retention among the patients for whom follow-up data were received from clinics by demographic and initial treatment factors. ResultsBetween October 2020 and September 2022, the MATTERS Network made 1349 referrals; 39.7 % originated from an ED and 47.8 % originated from telemedicine. For patients with available data, those referred from telemedicine were 1.64 times more likely to attend their initial clinic appointment and 2.59 times more likely be engaged in treatment at 30 days compared to those referred from an ED. More than two-thirds of patients referred from the emergency telemedicine environment followed up at their first clinic visit and more than half of these patients were still retained in treatment 30 days after referral. ConclusionsThe rates of initial clinic visit and 30-day retention when referred following a telemedicine evaluation are encouraging. Further development of telemedicine programs that offer evaluations, access to medications, and referrals to treatment should be considered.

Sensitivity and Specificity of a Neuropathic Screening Tool (Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, S-LANSS) in Adolescents With Moderate-Severe Chronic Pain

Neuropathic screening tools improve recognition of neuropathic pain in adults. Although utilized in pediatric populations, the sensitivity, specificity and methodology of screening tool delivery have not been compared in children. We evaluated the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in adolescents (10–18 years) referred to a tertiary pediatric pain clinic. History and examination by specialist clinicians and multidisciplinary assessment informed classification of the primary pain type. In a prospective cohort, scores were obtained at interview (S-LANSS interview; n = 161, 70% female), and following substitution of self-reported signs with examination findings in the primary pain region (Leeds Assessment of Neuropathic Symptoms and Signs, LANSS examination). Secondly, we retrospectively retrieved questionnaires self-completed by adolescents at their initial clinic appointment (S-LANSS self-completed; n = 456, 73% female). Thirdly, we explored relationships between patient-reported outcomes and S-LANSS scores. S-LANSS interview scores varied with pain classification, and S-LANSS self-completed scores were similarly highest with neuropathic pain (median [interquartile range]: 18 [11, 21]) and complex regional pain syndrome (21 [14, 24]), variable with musculoskeletal pain (13 [7, 19]) and lowest with visceral pain (6.5 [2, 11.5]) and headache (8.5 [4, 14]). As in adults, the cutpoint score of 12/24 was optimal. Sensitivity was highest with inclusion of examination findings and lowest with self-completion (LANSS examination vs S-LANSS interview vs S-LANSS self-completed: 86.3% vs 80.8% vs 74.7%), but specificity was relatively low (37.8% vs 36.7% vs 48%). High S-LANSS scores in non-neuropathic groups were associated with female sex and high pain catastrophizing. The S-LANSS is a sensitive screening tool for pain with neuropathic features in adolescents, but needs to be interpreted in the context of clinical evaluation (clinicaltrials.gov NCT03312881). PerspectiveThis article reports high sensitivity of the S-LANSS screening tool for identifying pain with neuropathic features in adolescents with moderate-severe chronic pain. However, as sensitivity is lower than in adult populations, further interdisciplinary evaluation is necessary to inform diagnosis and management.

Predicting Kidney Transplant Evaluation Non-attendance.

Non-attendance to kidney transplant evaluation (KTE) appointments is a barrier to optimal care for those with kidney failure. We examined the medical and socio-cultural factors that predict KTE non-attendance to identify opportunities for integrated medical teams to intervene. Patients scheduled for KTE between May, 2015 and June, 2018 completed an interview before their initial KTE appointment. The interview assessed various social determinants of health, including demographic (e.g., income), medical (e.g. co-morbidities), transplant knowledge, cultural (e.g., medical mistrust), and psychosocial (e.g., social support) factors. We used multiple logistic regression analysis to determine the strongest predictor of KTE non-attendance. Our sample (N = 1119) was 37% female, 76% non-Hispanic White, median age 59.4years (IQR 49.2-67.5). Of note, 142 (13%) never attended an initial KTE clinic appointment. Being on dialysis predicted higher odds of KTE non-attendance (OR 1.76; p = .02; 64% of KTE attendees on dialysis vs. 77% of non-attendees on dialysis). Transplant and nephrology teams should consider working collaboratively with dialysis units to better coordinate care, (e.g., resources to attend appointment or outreach to emphasize the importance of transplant) adjusting the KTE referral and evaluation process to address access issues (e.g., using tele-health) and encouraging partnership with clinical psychologists to promote quality of life for those on dialysis.

Developing a Cancer-Associated Thrombosis Clinic: Two-Year Experience

Background: Cancer-associated thrombosis (CAT) is a common comorbidity in patients with cancer. Prior trials have demonstrated that direct oral anticoagulants (DOACs) and low-molecular weight heparins (LMWHs) are safe and effective for CAT management. Despite these data, treatment of CAT is complicated by consequences of both cancers and cancer-directed therapies that can impact anticoagulation options. Methods: We developed the Northwestern Medicine CAT clinic in April 2020 to improve care by streamlining referrals for evaluation and management of CAT by a non-malignant hematologist. Patients were referred for either acute management of new VTE or for ongoing management of previously known VTE. Goal time-to-appointment for acute referrals was within 24 hours and for ongoing management within two weeks. Initial evaluations were completed by advanced practice providers with review by an attending classical hematologist and clinical pharmacist. We manually reviewed electronic health records of patients seen in the CAT clinic since its inception. Data collected included demographic, cancer diagnosis and cancer-directed therapy, CAT clinic recommendations, and recurrent VTE, bleeding and death within 6 months of initial CAT clinic appointment. We used descriptive statistics to assess referral and treatment patterns. Results: One hundred twenty-two patients (N=122) were seen by CAT clinic clinicians between April 2020 - April 2022, including 63 (51%) in the first year. Patients had a median age of 63 years and 56.4% were female. Appointments occurred in nearly equal proportion via telehealth (50.8%) and in-office visits (49.2%) during these two years; however, 78% of visits were telehealth during the first year, and only 25.4% during the second. Forty-three (35.2%) referred for acute management were seen at a median time of two days, and the remainder for ongoing management were seen at a median time of 10 days. Referrals were predominantly for PE (25.4%), concurrent PE/DVT (23.0%), and proximal lower extremity DVT (18.9%); however, consults included thrombi of the cerebral, pulmonary, and splanchnic veins, as well as tumor thrombi, arterial thrombi, and need for primary prophylaxis. Tumor types were categorized into nine groups, with the largest proportion consisting of gastrointestinal (25.4%), gynecologic (17.2%), and hematologic (17.2%) malignancies (Figure 1). DOACs were recommended in 47.5%, and LMWHs in 41% (Figure 2), with a similar proportion of DOACs prescribed between year one (47.5%) and year two (47.6%). Primary reasons for choosing LMWHs over DOACs were perceived bleeding risk (40%), tumor type (22%), and prior DOAC failure (20%). Twelve (9.8%) patients were advised to stop anticoagulation, due to lack of indication for 11 (91.7%) and perceived bleeding risk for one (8.3%). Four were referred for inferior vena cava (IVC) filter retrieval. At the time of evaluation, 16 (13.1%) patients were noted to have platelet counts <150,000/µL, but none had platelet counts <50,000/µL. Within 6 months of initial evaluation, 11 (9.0%) patients developed progressive or recurrent VTE. Fourteen (11.5%) patients experienced bleeding: eight (57.1%) had major bleeding episodes as defined by the International Society on Thrombosis and Hemostasis, and six (42.9%) had clinically-relevant non-major bleeding. Among major bleeding events, six (75%) were gastrointestinal and two (25%) intraabdominal in origin, with no identified intracranial hemorrhages. Twenty (16.4%) died during the follow up period. Seventy-six (61.8%) patients were seen for a follow up visit after initial consultation. Conclusion: Building the CAT clinic led to improved access to classical hematologists with thrombosis expertise to manage CAT. Historical wait times for this specialty have exceeded 90 days, while those referred to the CAT clinic had a median time-to-appointment of only nine days. Highlighting the complexity of CAT management, more than 40% of patients were not treated with DOAC, primarily related to perceived bleeding risk. Four patients were identified for IVC filter removal, suggesting there may be additional benefits to non-malignant hematologists beyond anticoagulant management. Decisions regarding treatment of individual patients with CAT remain complex, and access to thrombosis specialists provides additional expertise to optimize care. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Intimate Partner Violence During Recovery from an Orthopaedic Injury: An Exploratory, Prospective, Multicenter, Observational Cohort Study.

Orthopaedic injuries may lead to an increased incidence of intimate partner violence (IPV) during recovery as people dependent on others' help are at a higher risk for abuse. Additionally, there is a lack of understanding of how IPV affects injury recovery. In women being treated for an orthopaedic injury, we aimed to determine the number of new IPV disclosures in the 12 months after an injury and to explore the impact of IPV on recovery. We enrolled 250 female participants from 6 orthopaedic fracture clinics in Canada, the Netherlands, Spain, and Finland. IPV disclosure and clinical outcomes were assessed at the initial visit and during the 12-month follow-up period. Of 250 participants, 81 (32.4% [95% confidence interval (CI), 26.6% to 38.2%]) had a history of IPV in their lifetime and disclosed this at their initial orthopaedic clinic appointment. Twenty-one participants (12.4% [95% CI, 7.5% to 17.8%]) who did not disclose abuse at the initial visit disclosed IPV during the follow-up. In our a priori unadjusted analysis, disclosure of IPV at the initial appointment or a subsequent follow-up appointment was associated with a 32% lower likelihood of returning to a pre-injury level of function with no restrictions regarding responsibilities at home (hazard ratio, 0.68 [95% CI, 0.46 to 0.99]; p = 0.046). Participants disclosing IPV had lower health-related quality of life on the EuroQol-5 Dimensions (EQ-5D) at the 6-month-follow-up, with adjusted mean differences of -5.3 (95% CI, -10.2 to -0.4, p = 0.04) for the visual analog scale and -0.06 (95% CI, -0.11 to -0.01; p = 0.02) for the Function Index. They also had lower Function Index scores at the final 12-month follow-up visit, with an adjusted mean difference of -0.06 (95% CI, -0.10 to -0.02; p = 0.006). A surprisingly high percentage of women disclosed IPV within 12 months after the injury. Our exploratory results suggest that women who disclose IPV may have lower health-related quality of life. This study supports the need to optimize orthopaedic clinics to provide appropriate support for asking about and assisting individuals who experienced IPV. Additional research is warranted to further explore these findings. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Management of congenital melanocytic nevi in the plastic surgery clinic: Families' expectations and their persistent concern about malignancy.

Children with congenital melanocytic nevi (CMN) were historically managed with surgical removal to lower the risk of malignant transformation. The evolving literature over the last decade has indicated a significantly lower risk than previously estimated. Indications for excision currently revolve around aesthetic and psychosocial concerns. This study describes and evaluates the perspectives and expectations of patients and families referred to a pediatric plastic surgery clinic on CMN management. A two-part questionnaire was administered before and after an initial clinic appointment to evaluate patient and family concerns of lesion growth, risk of malignancy, treatment expectations, and stigmatization. Thirty questionnaires were completed for 11 male and 19 female patients, mean age 9.2years (1-25). Referring doctors (majority dermatologists) were rarely concerned about malignancy (8%), but parents listed it as a top reason for wanting the CMN removed (37%) and the most common expectation for the visit followed by information about surgical options and outcome. Before the clinic, 93% were at least "slightly" worried about CMN growth and 96% about malignancy, whereas 63% and 72%, respectively, after the clinic. Families want information about surgical excision and are concerned about malignancy, indicating lingering misinformation or misconception about melanoma risk. For the majority, CMN removal remains at least slightly important, presumably for aesthetic reasons and remaining concern about malignancy. Involved health care professionals should assure reliable and coherent patient information about MM risk, indications for surgery and expected outcome to best support families' decision-making.

Prevalence of Malnutrition and Feeding Difficulties in Children With Esophageal Atresia.

Growth and feeding problems have been described in children with esophageal atresia (EA). Ongoing gastrointestinal and respiratory complications such as Gastroesophageal reflux disease, esophageal dysmotility, strictures, and respiratory infections may contribute. The aim of the study was to document the prevalence of malnutrition and feeding difficulties and examine predictive factors, which may influence feeding and growth in children attending a multidisciplinary EA clinic in Sydney, Australia. A retrospective review of 75 children, ages 0 to 16 years, who attended a multidisciplinary EA clinic between 2011 and 2014. Data on demographics, comorbidities, nutrition, and mealtime behaviors were collected from their initial clinic appointment. Factors that may affect on growth and mealtime behaviors were identified and analyzed. Nine percent of children were malnourished and 9% were stunted. Infants, children with prior fundoplication, at risk of aspiration, or those who had surgery in the first year of life additional to EA repair were significantly more likely to be malnourished (P < 0.05). Fifty-four percent of children required texture modification at their meals, with parental concern being the most common reason. Younger children were less likely to be eating age-appropriate textures (P = 0.04) which improved after 5 years of age. Poor growth and inability to manage age-appropriate textures are often present in children with EA, particularly in the younger years. This highlights the need for early intervention in a specialist multidisciplinary EA clinic in which dietetics and speech pathology are available.

Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population.

Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS. We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes. The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS. In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.

Patients Attending Shared Medical Appointments for Metabolic Stone Prevention Have Decreased Stone Risk Factors.

Shared medical appointments (SMAs) have decreased patients' wait time to initial stone clinic appointment, standardized education, and increased exposure to nutrition therapy. We assessed the effectiveness of SMAs in reducing patients' urinary stone risk factors. Patients who established care in our stone clinic in an SMA between March 2012 and August 2015 were sequentially identified. After eliminating those without follow-up urine collections or whose urinary creatinine excretion between the two collections varied by >40%, 113 patients were included (M:F 63:50; 54 ± 15 years; body mass index [BMI] 30.6 ± 6.7). Results from before and after the SMA were compared with those from a similar cohort of patients who attended individual patient appointments (IPAs) for their first stone clinic visit (n = 63; M:F 37:26; 54 ± 14 years; BMI 30.1 ± 8.2). All patients received individualized medical therapy for stone prevention. After medical and nutritional therapy, SMA patients with elevated risk(s) at baseline achieved significant reductions in uric acid, calcium, and sodium; p ≤ 0.001 for all. Those with low urine magnesium, low urine volume, low urine pH, and/or low urine citrate at baseline achieved increases; p ≤ 0.0008 for all. IPA patients with elevated baseline risk factors achieved reductions in oxalate and uric acid (p ≤ 0.004 for both) but neither calcium nor sodium and an increase in citrate (p = 0.003) but not magnesium. Patients from SMAs reduced their stone recurrence risk and compared favorably with patients from IPAs. Contributing factors may include shorter time from stone event to appointment and more standardized education for patients attending SMAs.

The relationship between parental attitudes and behaviours in the context of paediatric chronic pain.

Within the context of paediatric chronic pain, parental attitudes are of particular importance given that they have the potential to impact on how parents respond to their child. The current study was designed to assess whether parental attitudes, such as parental confidence and beliefs in their child's ability to function in spite of pain, and parental catastrophising about their child's pain, are associated with parental pain-related behaviours known to be associated with poor child outcomes, such as protectiveness and high levels of monitoring. Participants were 138 child-parent dyads recruited from a tertiary chronic pain clinic. Patients were aged 8- to 17-years. Prior to the initial clinic appointment, parents completed validated measures of parental pain catastrophising and parental responses to their child's pain. Patients completed measures of functional disability and pain intensity. Parents who reported lower confidence in their child's ability to cope with the pain engaged in significantly more protective, monitoring and distracting behaviours, even when controlling for the child's recent level of functioning. They also took more days off work due to their child's pain. Parents who catastrophised more about their child's pain engaged in significantly more protective and monitoring behaviours, even when controlling for the child's recent level of functioning. Parental behaviours in response to their child's pain are significantly related to parental confidence in their child's coping and parental pain-related catastrophising. Clinical interventions may benefit from addressing parental attitudes, especially their confidence in their child's ability to function.

Changes to Initial Postexposure Prophylaxis Regimens Between the Emergency Department and Clinic

Changes to Initial Postexposure Prophylaxis Regimens Between the Emergency Department and Clinic

Patient attrition between the emergency department and clinic among individuals presenting for HIV nonoccupational postexposure prophylaxis.

Nonoccupational postexposure prophylaxis (nPEP) is recommended after a sexual or parenteral exposure to human immunodeficiency virus (HIV). Patients frequently seek care in an emergency department (ED) after an exposure and are usually referred to an HIV clinic for further management. There have been few data on determinants of attrition after presentation to EDs for nPEP. From July 2010 to June 2011, we prospectively recorded all referrals to nPEP programs from 2 large EDs at 2 academic medical centers in Boston, Massachusetts. Data were recorded on patient demographics, nature of potential HIV exposures, referrals to and attendance at HIV clinics, and reported completion of 28 days of antiretroviral therapy (ART). Multivariable logistic regression was used to evaluate risk factors for (1) patient attrition between the ED and HIV clinic follow-up and (2) documented completion of ART. Of 180 individuals who were referred to clinic follow-up for nPEP care from the ED, 98 (54.4%) attended a first nPEP clinic visit and 43 (23.9%) had documented completion of a 28-day course of ART. Multivariable analysis revealed older age (adjusted odds ratio [aOR], 0.96; 95% confidence interval [CI], .93-.99) and self-payment (aOR, 0.32; 95% CI, .11-.97) were significant predictors for failing to attend an initial HIV clinic appointment. Women were less likely than men to complete a 28-day ART regimen (aOR, 0.34; 95% CI, .15-.79). Commonly used nPEP delivery models may not be effective for all patients who present with nonoccupational exposures to HIV. Interventions are needed to improve rates of follow-up and completion of nPEP to reduce the risk of preventable HIV infections.

S78 Evalution of an ambulatory pleural service: costs and benefits: Abstract S78 Table 1.

Background Outpatient management of undiagnosed pleural effusions is increasing. Payment for managing these patients is usually based on standard outpatient Healthcare Resource Group (HRG) codes. For 2013/14, a new Best Practice Tariff (BPT) of £1534 has been introduced to further disincentivize emergency inpatient management. We audited our service and examined what effects this tariff may have when applied. Methods Our well-established tertiary pleural service serves a local population of around 540,000. New patients are seen in a weekly pleural clinic or in a daily respiratory admission avoidance (Hot) clinic, which had standard 2012/13 tariffs of £223 and £334 respectively. The service sees approximately 150 new effusion patients per year in clinic and 3 new patients per week in Hot. Around 50 medical thoracoscopies and 60 indwelling pleural catheter insertions are performed each year. We audited randomly selected patients from our large, prospectively-maintained database. All audited patients were seen as new pleural effusion referrals between 2008 and 2012. Diagnosis was confirmed after a minimum of 12 months’ follow-up. Results 146 patients were audited. Median age 76(range 21–93), 71% male. Final diagnoses were mesothelioma (n = 28,19%), lung cancer (n = 10,7%), breast cancer (n = 13,9%), other cancer (n = 31,21%), pleural infection (n = 15,10%), benign pleuritis (n = 11,8%) and other (n = 38,26%). 92% of patients avoided direct admission following their initial clinic appointment. 115 patients (79%) underwent ultrasound-guided pleural aspiration at their initial appointment and 63(43%) patients underwent subsequent pleural biopsy. For patients with malignancy, diagnostic sensitivity on first fluid cytology was 27% (adenocarcinoma n = 15,80%; mesothelioma n = 21,5%), and 93%(25/27) for medical thoracoscopy biopsy. Histological/cytological diagnosis took a median of 20 days (IQR 10–33) from presentation. There were no significant procedural complications noted (bleeding, pneumothorax, empyema). 97%(58/60) of patients surveyed rated the service as either very good or excellent. Conclusions Ambulatory management of undiagnosed effusions is efficacious, avoids hospitalisation in the vast majority and is preferred by patients. The 2013/14 pleural effusion BPT promotes admission avoidance by encouraging appropriate outpatient management. Trust reimbursement for practising in this way should facilitate enough resource to enable new pleural services to be established where required.

Improved aneurysmal subarachnoid hemorrhage outcomes: A comparison of 2 decades at an academic center

ObjectiveManagement of aneurysmal subarachnoid hemorrhage (aSAH) has evolved over the past 2 decades, including refinement of neurosurgical techniques, availability of endovascular options, and evolution of neurocritical care; their impact on SAH outcomes is unclear. Design/MethodsProspectively collected data of patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed. We compared survival to discharge and functional outcomes at initial clinic appointment postdischarge (30-120 days) in patients admitted between 1991 and 2000 (phase 1 [P1]) and 2000 and 2009 (phase 2 [P2]), respectively, using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5). ResultsA total of 1134 consecutive patients with aSAH were included in the analysis (P1 46.4%, P2 53.6%). There were higher rates of poor grade Hunt and Hess (P1 23%, P2 28%; P < .05), admission Glasgow Coma Scale score lower than 8 (P1 14%, P2 21%; P < .005), known medical comorbidites (P1 54%, P2 64%; P = .005), associated intraventricular hemorrhage (P1 47%, P2 55%; P < .05), and older population (P1 51.5%, P2 53.5%; P < .05) in P2. Good outcomes were more common in P2 (71.5%) compared with P1 (65.2%), with 2-fold adjusted odds of good outcomes after correction for various confounding factors (P < .001). ConclusionsOur institutional experience over 2 decades confirms that patients with aSAH have shown significant outcome improvements over time.

A mixed methods service evaluation of a pilot functional electrical stimulation clinic for the correction of dropped foot in patients with chronic stroke

To undertake a service evaluation of the pilot Lothian functional electrical stimulation (FES) clinic using both quantitative and qualitative methods and clinical practice reflection. Clinical guidelines recommend that FES, for the management of dropped foot after stroke, is delivered by a specialist team. However, little detail is provided about the structure and composition of the specialist team or model of service delivery. A pilot Lothian FES clinic was developed to explore the clinical value of providing such a service to stroke patients with dropped foot and identify any service modifications. Mixed methods were used to evaluate the service and included quantitative, qualitative and reflective components. Phase 1: Before and after service evaluation of patients attending the FES clinic between 2003 and 2007. Outcomes of gait velocity and cadence were recorded at initial clinic appointment and 6 months after application of FES. Phase 2: Qualitative research exploring patients with stroke and carers' experiences of the FES clinic. Data were collected via semi-structured interviews. Phase 3: A reflection on the service delivery model. Phase 1: 40 consecutive out-patients with stroke; Phase 2: 13 out-patients with stroke and 9 carers; Phase 3: Three specialist physiotherapists engaged in running the FES clinic. Statistically significant improvements (p < 0.001) were demonstrated in gait velocity and cadence. Qualitatively, one super-ordinate theme 'The FES clinic met my needs' emerged. Within this were four sub-themes, namely 1. 'Getting to grips with FES wasn't difficult'; 2. 'It's great to know they're there'; 3. 'Meeting up with others really helps' and 4. 'The service is great but could be better'. On reflection, minor modifications were made to the service delivery model but overall the service met user needs. This dedicated FES clinic produced positive physical outcomes and met the needs of this chronic stroke population.

Treatment Engagement: A Neglected Aspect in the Psychiatric Care of Suicidal Patients

Treatment Engagement: A Neglected Aspect in the Psychiatric Care of Suicidal Patients

The Extended Scope Physiotherapist in Orthopaedic Out-Patients – An Audit

We undertook an audit of the activity of the extended scope physiotherapists (ESPs) in our unit. We assessed their activity against three benchmark data: (i) independent assessment and management by the ESP of 85% of patients seen by them; (ii) no patient to be re-referred to a surgeon with the same problem; and (iii) patient satisfaction rate of 89%. All new referrals seen by the ESPs over the 6-month period between July 2002 and December 2002 were included in the audit. Patient medical records were reviewed retrospectively. Patients were contacted by telephone 12 months after their initial clinic appointment to obtain patient satisfaction scores. In the 6-month period, 150 patients (75 male, 75 female) were seen. Their median age was 43.5 years (range, 17-85 years). Their main complaints related to the spine (42%), knee (33%), shoulder (18%), or other site (7%). The ESPs saw and managed 82/150 patients (55%) independently. Consultant review was required for 81% of shoulder cases, 34% of knee cases and 11% of back cases. GPs re-referred 4/150 patients (3%). We successfully contacted 126 patients by telephone: 97 (77%) were satisfied with their management by ESPs. Of patients who were dissatisfied, 76% did not see a consultant at any stage in their management. ESPs fulfilled a useful role in our orthopaedic out-patient clinic particularly in the back clinic. The percentage of independently managed patients was much lower than the figure quoted in the literature. We suspect that the published literature does not reflect modern referral patterns and recommend that time for review of new patients seen by ESPs should be factored into consultant's clinic time. Patients' expectations may be a barrier to achieving greater levels of patient satisfaction.

Outcomes in 2748 patients referred to a colorectal two‐week rule clinic

To assess the 3-year outcomes of a nurse-led, one-stop, 2-week rule (TWR) clinic for suspected colorectal cancer (CRC) in a large teaching hospital. Data were collected prospectively from January 2002 to December 2004. In total, 2748 patients were seen over the 3-year period. The ratio of male:female subjects was 1190:1558 (43%:57%). Median age at presentation was 66 years (range 17-96). A total of 1363 (49.6%) nonconforming referrals were made; 1300 patients (47.3%) underwent flexible sigmoidoscopy during their initial assessment in clinic; 1439 patients (52.4%) underwent a barium enema during the course of their investigation; 2503 patients (91.1%) were seen within 14 working days. The median overall wait for the initial clinic appointment was 10 days. The annual number of patients seen was similar over the 3-year period. A total of 174 cancers (6.3%) were identified which accounted for 36.4% of all CRCs diagnosed during the study period. Nineteen cancers presented in the nonconforming group (1.6% of all non-conforming patients). Rectal tumours accounted for 59.8% (n = 104) of all cancers diagnosed while right-sided tumours accounted for only 10.9% (n = 19). Advanced tumours accounted for 73.0% (n = 127) of the total; 133 (76.4%) cancer patients underwent some form of surgical intervention. A specialist nurse-led, one-stop TWR clinic for suspected colorectal cancer is sustainable and can be run successfully with over 90% of referrals seen within the targeted time period. The proportion of non-conforming referrals was high and a large number of advanced and unstaged tumours was observed. Low numbers of proximal tumours were detected.