Non-referred Cases Research Articles

"It's complicated…": Exploring second stage caesarean sections and reasons for non-performance of assisted vaginal births in Kenya: A mixed methods study.

Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues.

Analysis of News Media-Reported Snakebite Envenoming in Nepal during 2010-2022.

Snakebite envenoming is a well-known medical emergency in the Terai of Nepal in particular. However, there is an epidemiological knowledge gap. The news media data available online provide substantial information on envenomings. Assessing this information can be a pristine approach for understanding snakebite epidemiology and conducting knowledge-based interventions. We firstly analyzed news media-reported quantitative information on conditions under which bites occur, treatment-seeking behavior of victims, and outcomes of snakebite envenomings in Nepal. We analyzed 308 Nepalese snakebite envenomed cases reported in 199 news media articles published between 2010 and 2022 using descriptive statistics, Wilcoxon, and Chi-square tests to know why and how victims were bitten, their treatment-seeking behavior, and the outcomes. These envenomated cases known with substantial information represented 48 districts (mostly located in the Terai region) of Nepal. These envenomings mostly occurred in residential areas affecting children. Generally, envenomings among males and females were not significantly different. But, in residential areas, females were more envenomed than males. Further, victims' extremities were often exposed to venomous snakebites while their active status and these episodes often occurred at night while victims were passive during snakebites indoors and immediate surroundings of houses. Snakebite deaths were less among referred than non-referred cases, males than females, and while active than passive conditions of victims. The most of reported envenomed patients were children, and most envenomings were due to cobra bites. Consultation with traditional healers complicated snakebite management. In most cases, deaths that occur without medical interventions are a severe snakebite consequence in Nepal. Further, several deaths in urban areas and mountains and higher hills of Nepal suggest immediate need of snakebite management interventions in the most affected districts. Therefore, there is an urgent need to immediately admit Nepalese snakebite victims to nearby snakebite treatment centers without adopting non-recommended prehospital interventions. The strategies for preventing snakebite and controlling venom effects should also include hilly and mountain districts where snakebite-associated deaths are reported.

Barriers to the identification of possible organ donors among brain-injured patients admitted to intensive care units.

Improving organ donation rates requires better detection of possible organ donors, which in turn necessitates identifying barriers preventing the identification of possible organ donors. The objectives of this study were to determine the actual rate of possible deceased organ donors among nonreferred cases and to identify barriers to their identification as possible donors. This retrospective observational study used 6 months of data collected from two intensive care units (ICUs). Possible organ donors were defined as patients with a Glasgow Coma Scale score <5 and evidence of severe neurological damage. Barriers that led to the nonidentification of these patients as possible organ donors were also identified. Fifty-six of 819 patients admitted to the ICUs during the study period were detected as possible organ donors, representing a 6.83% possible organ donor detection rate. Nonclinical barriers to the identification of possible organ donors were found to be more significant than clinical barriers (55% vs. 45%, respectively). The most significant nonclinical barrier was an unknown reason, despite patients being medically suitable for deceased organ donation and fulfilling the criteria for possible organ donor classification. Unresolved sepsis was the main clinical barrier. The significant rate of unreferred possible deceased organ donors found in this study reveals the need to increase awareness and knowledge among clinicians of the proper detection of possible donors at an early stage to avoid the loss of possible deceased organ donors, and thereby increase the deceased organ donation rate in Malaysian hospitals.

Risks and Benefits of Artificial Intelligence in Teledermatology

Background Recently, deep convolutional neural networks (DCNNs) became of interest as decision support systems for dermoscopic and clinical analysis of skin diseases. Application of artificial intelligence in teledermatology (TD) has been recently reported in several studies as a tool for augmented intelligence. Objective In this session, a critical discussion of the opportunities, limitations, and risks of AI in TD will be presented with special attention to recent published studies. Methods We reviewed the literature in PubMed and EMBASE databases in the period of January 2018 to November 2021 with the search terms of dermatology, skin cancer, deep learning, and AI (review of the Regulation of Medical Devices, EU 2017/745). Results A clear definition of the clinical use of AI in TD has to be considered: primary TD from patients to nurses, primary care physicians or general dermatologists; secondary TD from primary care physicians or nurses to dermatologists; or tertiary TD from dermatologists to hospital dermatologists. In some health models of TD for nurses or primary care physicians, AI assistance can lower the rates of recommending a biopsy or specialist referral, increase self-reported diagnostic confidence, and help to achieve higher diagnostic agreement rates (with dermatologists) in nonreferred cases. The main limitations of the use of AI in TD are the lack of large longitudinal studies, the lack of interpretability of the CNN, biases in the databases and unrepresented dermatological conditions for training, limited representation of different ethnicities, standardization of clinical information and of the images, liability, and privacy issues. How to implement the concept of augmented intelligence in clinical practice with referral TD consultations including structured clinical information and good-quality images will need further research and education among end users. Even if the interface is used for either store-and-forward or live TD, interactive TD is, in principle, straightforward for AI systems, and different TD modalities have particular technological requirements that can reduce their efficacy. Finally, AI systems in TD are under the umbrella of medical device regulatory frames, and specific certification is compulsory. This regulation has the benefit of assuring the quality of the new AI systems and diminishing their risks, but it can simultaneously delay the incorporation of AI tools in clinical practice. Conclusions AI has the potential to improve the results of the technology in different aspects in multiple modalities of TD. However, the evidence is weak, and several barriers and limitations have to be resolved for their integration in clinical practice. Conflicts of Interest None declared.

Plastic Surgical Procedures for Lower Limb Reconstruction at a Tertiary Hospital in Nepal.

This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Application of the WHF Criteria for Echo Diagnosis of RHD: A Sonographer's Perspective from the SACHRD Study

Introduction: Screening for rheumatic heart disease (RHD) using echo has improved detection rates amongst indigenous children. The SACRHD study conducted in 2016 recruited seven cardiac sonographers to perform echo screening in schools across metropolitan, regional and remote locations in South Australia. Method: The cases referred to a Cardiologist for review by the sonographers were recorded. Cases of known RHD or congenital heart disease (CHD) were excluded. 180 (10%) or non-referred cases were also reported. At the conclusion of the study, sonographers were surveyed about the ease of application of the WHF echo criteria and to highlight any challenges encountered. Results: 6/7 (85.7%) of sonographers reported they were “confident” or “very confident” identifying normal and definite RHD cases, while only 4/7 (57.1%) were confident identifying borderline cases. No sonographers felt “very confident” identifying excessive mitral valve leaflet tip motion, chordal thickening, or thickening of the aortic valve. The Cardiologist was in agreeance with sonographer identification in 13/47 (27.7%) of RHD cases and 15/21 (71.4%) of CHD cases. Conclusion: Sonographers participating in the SACRHD study correctly identified borderline or definite RHD in 27.7% of cases they referred. No non-referred scan was found to have any abnormality demonstrating a very high negative predictive value for sonographer screening. Borderline cases were perceived to be most challenging to classify with sonographers feeling least confident identifying with excessive mitral valve leaflet tip motion, chordal thickening, and thickening of the aortic valve.

Clinical effectiveness of the Manchester Glaucoma Enhanced Referral Scheme

BackgroundGlaucoma referral filtering schemes have operated in the UK for many years. However, there is a paucity of data on the false-negative (FN) rate. This study evaluated the clinical effectiveness...

P07 * ARE ALL PATIENTS WITH SUSPECTED BRAIN TUMOUR ON CRANIAL IMAGING REFERRED PROMPTLY FOR MDT DISCUSSION?

INTRODUCTION: The IOG for Brain and CNS tumours advises that all new cases of suspected CNS tumour should be referred to the Brain & CNS tumours MDT for discussion within a strict timescale. We audited new tumour referrals to MDT using the following standards: (1) All newly diagnosed/ suspected brain tumours are logged to the MDT database; (2) Logging to the database should be done within 7 days of image reporting. METHOD: A retrospective study of all radiology reports of CT/MRI head scans performed in two hospital Trusts in a 4 week period. Scans were identified from the PACS system of each Trust and each scan report was manually reviewed for a suspected new diagnosis of brain tumour. All positive scans were correlated with the MDT database. RESULTS: All radiology reports for CT/MRI head scans performed in the period 30/09/13-27/10/13 were assessed. 2125 scans were identified and, of these, 42 were reported as showing possible/definite new diagnosis of brain tumour. (22 male, 20 female, mean age 62.5). Only 48% (n = 20) of cases were subsequently referred and logged to the MDT database, with 50% (n = 10) logged within 7 days. All high grade primary brain tumours (n = 6) were referred to MDT. Of the non-referred cases, the most common diagnosis was cerebral metastasis (59%). Review of non referred cases indicated that reasons for non-referral included: (1) Clinical judgement conflicted with guidelines; (2) Patient died; (3) Re-scan excluded tumour diagnosis. Common reasons for delayed referral were: (1) Physician awaited a re-scan; (2) Benign tumour diagnosis. CONCLUSION: Improvement of the awareness regarding the criteria for referral to Brain tumour MDT is needed, especially in metastatic and non-high grade Tumours.

학령전기 아동언어장애 진단을 위한 조사연구

본 논문은 충남 <TEX>${\bigcirc}{\bigcirc}$</TEX>군에서 4년 동안 만 3~6세 총 193명 아동에게 실시한 말 언어장애 검사 결과를 기초로 아동언어장애 진단의 민감도와 특이도를 알아보았다. 공식언어검사의 민감도가 낮고, 장애판정 가능성이 높은 아동이 치료에 의뢰되는 비율이 낮으며, 아동과 친숙한 사람의 보고형 체크리스트가 장애 진단에 유용할 수 있음을 제안하였다. PRES, REVT, KOSECT 및 APAC의 결과가 3%ile미만이면 통과하지 못한 것으로 판정했고, 5, 6세 아동의 교사에게 CCC2를 실시해 보고형 검사가 장애판정에 유용한지 조사했다. 장애로 판정받은 아동은 89.4%(민감도), 정상아동은 76.3%(특이도) 구별했다. 언어장애 가능성이 있는 아동이 치료에 의뢰되었는지 조사한 결과, 민감도 10.5%, 특이도 99.2%였다. CCC2의 GCC는 장애 가능성 집단과 그렇지 않은 집단에서 통계적으로 유의한 차이가 있었다. A total of 193 children between three and six years of age were given tests by using the PRES, REVT, KOSECT, and APAC. A specificity between referred and non-referred cases was not high. In the current study, the sensitivity of formal tests was insufficient. But combining of parental report with formal language tests could provide good criteria for identifying language impairment. The CCC-2 may provide an effective means to identify language difficulties using a standardized approach.

Identifying language impairment in children: combining language test scores with parental report

Children who meet language test criteria for specific language impairment (SLI) are not necessarily the same as those who are referred to a speech and language therapist. To consider how far this discrepancy reflects insensitivity of traditional language tests to clinically important features of language impairment. A total of 245 twin children, 52 of whom had been referred to a speech and language therapist for assessment or intervention, were studied. They were given a battery of language tests and their parents completed the Children's Communication Checklist - 2 (CCC-2). Language tests that stressed verbal short-term memory were best at distinguishing clinically referred from other cases; narrative and vocabulary tasks were less effective. A discriminant function analysis identified a combination of language test and parental report measures as giving the best discrimination between referred and non-referred cases. Nevertheless, of 82 children classified as language impaired by the discriminant function, 44 had never been referred to a speech and language therapist. These did not appear to be false-positives; they scored at least as poorly as referred cases on literacy tests. They had significantly lower socio-economic backgrounds than referred cases. Language test scores provide important information about which children are at risk of academic failure, though this varies from test to test. Reliance on language tests alone, however, is insufficient; a parental report provides important complementary information in the diagnostic process. Children of low socio-economic status with language problems are particularly likely to have no contact with speech and language therapist services.

Evaluation of a Population-Based Program of Expedited Partner Therapy for Gonorrhea and Chlamydial Infection

To evaluate a partner notification program for gonorrhea and chlamydial infection that involves communitywide access to free patient-delivered partner therapy (PDPT) and use of case-report forms to triage patients to receive partner notification assistance. We evaluated program components in randomly selected cases and compared outcomes before and after program institution. Following institution of the program, the percentage of cases who received PDPT from their diagnosing clinician increased from 5.6% to 16% (adjusted OR 3.2, 2.5-4.1). Among randomly selected cases, those referred to the health department via the case-report form were significantly more likely than nonreferred cases to have untreated sex partners (76% vs. 35%, OR 6.0, 95% CI 4.5-8.0), to accept PDPT from the health department (36% vs. 14%, 3.3, 95% CI 2.4-4.7), and to request that health department staff notify a partner for them (11% vs. 3%, OR 3.5, 95% CI 1.8-6.7). The percentage of cases classified as having all of their partners treated increased from 39% to 65% concurrent with institution of the program. A public health program that promotes routine use of PDPT and referral of selected patients for partner notification assistance appears to have improved partner notification outcomes.

Resources Required for Resection of Large Sessile Colon Polyps

Background: Large sessile colon polyps (≥2 cm) (LSP) are often referred for surgery. This may be due to risk of bleeding and perforation in removal of LSP when compared to small polyps. High costs, procedure time and accessory use may also be a deterrent to endoscopic resection. Objective: To describe the resource utilization during endoscopic resection of LSP. Design: Procedure time, medication use, accessory use, and recovery time were recorded for 184 consecutive patients with LSP. Controls were 184 consecutive patients with resection of only sessile polyps ≤ 2 cm in size or pedunculated polyps. Results: Colonoscopy in patients with LSP averaged 51.4 min compared to 20.0 min for the control group (p < 0.0001). Recovery time was 31.6 min for the LSP group compared to 24.8 min for the controls (p < 0.0001). 62.5% of patients in the LSP group were referred LSP removal by another endoscopist. Time in procedure for referred patients with LSP was 55.4 min vs. 44.3 min for non-referred patients with LSP. Polypectomy technique and use of devices differed between the two groups. In the LSP group, hot snare (95% vs 20%; p < 0.0001), submucosal injection (80% vs 2%; p < 0.0001), piecemeal technique, India Ink and ablation techniques were more frequently used, while the control group had cold snare and cold forceps utilized more often (all p < 0.0001). Comparing referred LSP removals to the non-referred cases, submucosal injection was used in more of the referred cases (86% vs 71%; p = 0.0161). Ablative techniques (usually argon plasma coagulation) were used for some part of the LSP in 75% of the referred group compared to 52% of the non- referred group (p = 0.0008). No other differences between referred and non-referred groups were found. Conclusions: Since reimbursement for resection of LSP is not substantially greater than for small polyps, the long procedure time required for resection of large sessile colon polyps and the large amount of ancillary equipment needed are likely deterrents to endoscopic resection. To facilitate increased use of endoscopic resection of LSP, technical developments that reduce the expertise, risk and time required for endoscopic resection, and higher reimbursement are needed.

Anaplastic thyroid cancer in British Columbia 1985–1999: a population-based study

To review the outcome of patients diagnosed with anaplastic thyroid carcinoma in British Columbia between January 1985 and December 1999. Seventy-five patients were identified. Survival curves were calculated using Kaplan-Meier estimates, and the charts of the 62 patients referred to a British Columbia Cancer Agency (BCCA) facility were reviewed. All cases: 51 out of 75 patients (68%) were women; median age of all patients was 74 years. The overall- and cancer-specific 5-year survival rates for the whole group were 5%. non-referred cases: nine out of 13 patients were women; median age at diagnosis 84 years. Eleven of the 13 patients died within 1 month of diagnosis. Referred cases: 42 out of 62 patients were women; median age 72 years; median survival 5.1 months; 1-year survival 19%. Forty-eight patients presented with tumours that extended through the thyroid capsule, 10 presented with distant metastases. Four patients had a total thyroidectomy, nine a partial thyroidectomy, and 49 a biopsy only. Fifty-seven patients received radiotherapy, nine of these had concurrent chemotherapy: Thirty-three patients received less than 40 Gy and 24 patients received 40 Gy or more. Median survival was longer (9 vs 3 months) in patients receiving 40 Gy or more; this group included four patients who had prolonged survival. Long-term, disease-free survival was achieved in a few patients who were able to receive high-dose radiotherapy, preferably after adequate surgery.

Referral for genetic counseling after the birth of a child with a congenital anomaly in the Northern Netherlands.

Children/fetuses born with a congenital anomaly are recorded in a local registry of congenital anomalies in the Northern Netherlands. Parents of these children/fetuses often have questions about cause, prognosis, and recurrence risk. Referral to a genetic clinic is one way to obtain information concerning these questions. We were interested in determining to what extent parents were referred for genetic counseling, and investigated the non-referred cases for the estimated need for referral. Furthermore, we measured whether referral rates had improved following the study carried out by Cornel et al. [1992] for the same region. We evaluated data on couples referred or not referred for 2,964 registered children/fetuses during the birth years 1992-1997. The parents of 528 cases (18%) had been referred for genetic counseling. Investigation of the 2,436 non-referred cases showed a high number (1287/53%) of cases with a supposedly "low need for referral." If we consider the remaining 1,149 cases with a moderate or high need for referral to the genetic clinic, the ideal uptake rate is 57% (1149 +/- 528 = 1677 cases) instead of the previously mentioned 18% (528 cases). We concluded that nearly four out of 10 parents of children/fetuses with a congenital anomaly who were considered suitable for referral to the genetic clinic did not make use of this option. Despite increased familiarity with genetics over the years among the community in general and health-care professionals in particular, the EUROCAT registry does not show an improvement in the uptake rate of cases registered with the genetic clinic.

Compliance with practice guidelines for node-negative breast cancer.

Practice guidelines for cancer management have been in use in the province of British Columbia (BC), Canada, since the mid 1970s. To evaluate practice guideline compliance, treatment received was compared with treatment recommended in a population-based cohort of women with breast cancer. All incident cases (n = 939) of invasive, pathologically node-negative breast cancer diagnosed in 1991 were identified from the BC Cancer Registry. Treatment details were abstracted from cancer clinic records for cases referred to the BC Cancer Agency (BCCA) (n = 661) and original source documents for nonreferred cases. Management decisions were considered compliant if the patient received the recommended treatment or was entered onto a randomized trial of the modality being assessed. Overall compliance with adjuvant therapy guidelines was 97% for radiotherapy, 96% for chemotherapy, and 89% for tamoxifen. An oncology specialist was consulted by 94% of patients with an indication for adjuvant treatment and by 58% of those without an indication (odds ratio [OR] = 10.7; 95% confidence interval, 7.0 to 16.4). Compliance with a guideline to deliver radiotherapy was 95%; with chemotherapy, 77%; and with tamoxifen, 68%. Compliance with a guideline that stated no adjuvant treatment was indicated was 99% for radiotherapy, 98% for chemotherapy, and 92% for tamoxifen. Noncompliance among patients with an indication for treatment was related to nonreferral to an oncology specialist and less complete implementation of guideline changes in the community as compared with cancer center practices. Compliance was high, but scheduled updating and more effective community implementation could further improve consistency of care.

Population surveys of psychiatric disorder and the need for treatment

A central purpose of psychiatric community surveys is the amplification of the clinical picture by studying non-referred cases. However, this demands an operationalized method of identifying cases. The choice of case definition determines both the prevalence of the disorder in the community and how community cases compare with referred cases. Usually case definitions are set with a fairly low threshold and include quite mild conditions. The recent use of the PSE and the DIS has led to reported prevalences of credible consistency. However, the relatively inclusive criteria for defining, for instance, affective disorders makes it difficult to equate prevalence with the need for treatment. Affective disorders in the clinic are associated with much greater impairment of social performance than non-referred cases. It is argued here that the evaluation in the community of the need for treatment and services should be done directly, by adapting new techniques of need assessment. Only thus can the necessary allocation of resources be estimated.

Characteristics of Competency Referral Defendants and Nonreferred Criminal Defendants

This study examines correlates of referral for evaluation of competency to stand trial. Two hundred and four arrestees were studied; one-half of the cases included referrals for evaluation of competency. Characteristics of referred and nonreferred cases are examined. Several variables appear to be associated with such referrals, including the defendant's marital status and age, the history of prior contact with both the mental health and criminal justice systems, and the presence or absence of impulsive or violent behavior during the commission of the crime. Defendants’ personal characteristics seem more closely associated with referral than do demographic or crime characteristics. Directions for future study are suggested.