Outpatient Specialty Clinic Research Articles

Prospective Randomized Controlled Trial Comparing Laparoscopic Palomo Surgery versus Scrotal Antegrade Sclerotherapy in Adolescent Varicocele.

Varicocele is a common condition in adolescence and the most common correctable cause of infertility. This study aimed to analyze and compare the outcomes of scrotal antegrade sclerotherapy (SAS) and laparoscopic Palomo surgery (LPS) in a tertiary referral centre. Patients with left grade 3 varicocele indicated for surgery were prospectively enrolled and randomly allocated to the SAS and LPS groups, with their respective contralateral normal testes taken as controls. The primary outcome measures were clinical varicocele recurrence, testicular catch-up growth, and post-operative hydrocele. All patients were evaluated clinically and using Doppler ultrasound by radiologists. From 2015 to 2020, 113 patients completed the study and were statistically analyzed (SAS, n = 57; LPS, n = 56). All patients had significantly smaller testes pre-operatively that the testicular volume differences with control testes were -23% in SAS and -19% in LPS. At 12-month follow-up, there were no statistical significant difference in clinical recurrences between the 2 groups (SAS = 5.3% vs LPS = 5.4%, P>.05, non-inferiority test). Testicular catch-up growths were observed in both groups, the mean testicular volume difference between the treatment and control testes reduced from -23% to -8.1% in SAS (P<.001) and -19% to -9.3% in LPS (P<.001) at 12-month follow-up. There was no post-operative hydrocele in SAS compared to 7 in LPS (0% vs 13%, P = .006). Both SAS and LPS are safe and effective procedures for treatment of adolescent varicocele with significant positive effect on testicular catch-up growth. SAS is not inferior to LPS in terms of clinical recurrence rate and with significantly less post-operative hydrocele.

Enuresis and upper airway obstruction: BNP and ADH hormones behavior before and after airway surgery.

Upper airway obstruction (UAO) is a common condition in all pediatric population, with a 27% prevalence. Primary monosymptomatic nocturnal enuresis (PMNE) is a condition related to UAO in 8% to 47% of these children. The specific pathophysiological mechanism of this bond is not well understood. Some authors suggest a connection between brain natrituretic peptide (BNP) and anti-diuretic hormone (ADH) during sleep. The aim of this study was to evaluate hormone profile (ADH and BNP) and improvement in dry nights in a sample of children before and after surgical treatment of the UAO. This is a longitudinal prospective interventionist study in children, 5 to 14 years of age, with UAO and PMNE recruited in a specialty outpatient clinic. Children presenting UAO and PMNE were evaluated with a 30-day dry night diary and blood samples were collected to evaluate ADH and BNP before and after upper airway surgery. Data were analyzed prior to surgery and 90-120 days after surgery. Twenty-one children with a mean age of 9.7 years were included. Mean BNP before surgery was 116.5 ± 126.5 pg/mL and 156.2 ± 112.3 pg/mL after surgery (p<0.01). Mean ADH was 5.8 ± 3.2 pg/mL and 14.6 ± 35.4 before and after surgery, respectively (p=0.26). The percentage of dry nights went from 32.3 ± 24.7 before surgery to 75.4 ± 33.4 after surgery (p˂0.01). Surgery for airway obstruction contributed to an increase in BNP without increasing ADH. A total of 85.8% of the children presented partial or complete improvement of their enuresis.

Clinical characteristics and mortality of patients with heart failure in Southern Sweden from 2013 to 2019: a population-based cohort study

ObjectivesTo describe clinical characteristics and prognosis related to heart failure (HF) phenotypes in a community-based population by applying a novel algorithm to obtain ejection fractions (EF) from electronic medical records.DesignRetrospective...

Epidemiological Analysis of Foot and Ankle Injuries in Athletes: Experience of a Single Specialized Center

Category: Sports; Ankle Introduction/Purpose: The number of professional and amateur athletes has increased, consequently leading to an increase in the incidence of sports injuries. Understanding the epidemiological profile of foot and ankle's injuries in athletes is relevant for the prevention and treatment its occurrence. As far as we know, there is a lack of studies that report the epidemiological profile of athletes with foot and ankle disorders considering different sports. The aim of this study is to describe the epidemiology of foot and ankle injuries in athletes treated at an outpatient clinic specializing in injuries resulting from sports practice. The primary hypothesis is that ankle instability is the most frequent injury in athletes in the foot and ankle specialty outpatient clinic. Methods: Observational, retrospective, descriptive and comparative level IV of evidence study. The sample consisted of patients treated at an outpatient clinic specializing in foot and ankle injuries in sport, between January 1, 2015 and December 31, 2020. Three certified orthopedic physicians reviewed the charts and documented patient demographics, sport, diagnosis and lesion laterality. Age was analyzed according to age groups. The inclusion criteria were patients practicing amateurs or sports professionals of all age groups. We only count the first visits and the main modality and diagnosis of the patient. Exclusion criteria were insufficient data documented in chart, injuries that did not occur secondary to sports practice, and patients with conditions unrelated to the ankle and foot. Statistical analyzes were performed using software: SPSS V20, Minitab 16 and Excel Office 2010. We performed a multivariate logistic regression analysis to verify the association of gender, age and laterality with the main injuries documented. Results: A total of 763 patients (387 men and 376 women) met the inclusion criteria. The mean age was 35 years (SD= +-14.1; min=8.9; max=77). The most prevalent age group was young adults with 51.7% and the least prevalent was children with 1.4%. The most prevalent diseases were chronic lateral ankle instability (n=134, 17.6%), acute lateral ankle sprain (n=120, 15.7%) and plantar fasciitis (n=69, 9%). The multivariable analysis by logistic regression identified as a risk factor for lateral ankle instability the age group of young adults and females. In acute lateral ankle sprain, age was identified as a risk factor with statistical significance. In overuse injuries, only the female gender was evidenced as a risk factor. In non-insertional Achilles tendinopathy, bilaterality was associated as a risk factor with disease while in insertional Achilles tendinopathy, only the male gender was identified as a risk factor, as well as in Achilles tendon rupture. Conclusion: The literature specifically describing foot and ankle injuries during sport is limited, despite being highly prevalent injuries. Our work correlated several factors such as age, gender and laterality with specific sports through multivariate analysis, adding epidemiological data to the literature that help in the prevention and treatment of foot and ankle injuries in sports.

Health professionals’ views of medical teleconsultation uptake in the Brazilian Unified Health System: A description using the NASSS framework

BackgroundThe COVID-19 pandemic accelerated efforts to deploy and regulate medical teleconsultation in Brazil. Studying the Brazilian Unified Public Health System (SUS) experiences in implementing teleconsultations can help to inform their sustainability. This study identifies the changes required to integrate specialized teleconsultation in local workflows in SUS. MethodsA case study of teleconsultation performed by a University Hospital and a Municipal Specialty Outpatient Clinic in the south of Brazil collected information from two focus groups with specialised doctors, two key informant interviews and associated documents. The Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework domains of condition, technology, proposal value, users and organization informed a qualitative thematic analysis of this data. ResultsSeveral forms of teleconsultation were used to manage paediatrics and endocrine conditions including instant messaging, WhatsApp, telephone calls and video consultations which were also used for dermatology. In Brazil, telephone interactions are not considered teleconsultation. In contrast, video consultations were longer than face-to-face appointments, facilitate the understanding and evaluation of conditions, and offered continuity of care, comfort, and safety, without the need for patients to travel, reducing the risk of infection. Patients accepted video consultations to varying degrees but some found it difficult to use the technology. The willingness of doctors to provide any form of teleconsultation was important. Management support was key to defining workflows, coordinating care pathways, and providing technical support. ConclusionsThis study highlights particularities of teleconsultation uptake for the included specialities. The NASSS framework provides a useful means of identifying the changes to enable teleconsultation continuity for specialised care in SUS.

Brief adjunctive mindfulness-based cognitive therapy via Telehealth for anxiety during the COVID-19 pandemic

ABSTRACT Background and Objectives While cognitive–behavioral therapy is a highly efficacious treatment for anxiety, additional research is needed to identify adjunctive interventions that may augment treatment outcome. Design In response to the COVID-19 pandemic, we conducted an open feasibility trial of brief (i.e., four 75- to 90-minute sessions) mindfulness-based cognitive therapy (MBCT) for anxiety via telehealth for patients (N = 23) receiving individual CBT at an outpatient specialty clinic. Methods Self-report measures of home practice compliance (weekly), intervention acceptability (post-intervention), mindfulness and self-compassion, anxiety and depressive symptoms, and transdiagnostic processes (pre- and post-intervention) were administered as part of routine clinical practice. Results Results indicated good retention and attendance rates, few technical difficulties, good home practice compliance, and high levels of perceived importance. Participants indicated that they would highly recommend the group to others and also recommended extending the group beyond four sessions. There were significant improvements in mindfulness and self-compassion and reductions in intolerance of uncertainty, anxiety sensitivity, distress intolerance, emotion dysregulation, and anxiety symptoms from pre- to post-intervention. Conclusions Brief MBCT as an adjunctive treatment for anxiety via telehealth is feasible and acceptable, and shows promise in terms of engaging treatment targets and transdiagnostic processes and reducing anxiety symptoms.

Designing variable-sized block appointment system under time-varying no-shows

We consider the tactical problem of optimizing the capacity of a block appointment system with time-varying no-show and random service duration. The problem characteristics are motivated by a real-life case study of two outpatient specialty clinics in the US, where time-of-day variation in appointment attendance was observed. We aim to determine the block size (patients to be assigned in each time period) such that the weighted sum of block-wise waiting- and idle-times (or total cost) are minimized. First, we consider optimizing the capacity of a single block appointment system (SBAS) as a special case of the inverse newsvendor problem, and develop an analytical closed-form solution under the assumption of normally distributed service time. Also, a stochastic integer programming (SIP) model is developed to solve SBAS for any service time distribution. Subsequently, the SIP model is extended to determine the block size of the variable-sized multi-block appointment system (VSMBAS) by treating it as a sequential inverse newsvendor problem. Owing to the computational complexity of the SIP, we employ sample average approximation to estimate the expected total cost. Numerical studies considered several realistic clinic settings, and the results demonstrated that integrating time-varying no-shows for block size determination will considerably improve schedule efficiency as opposed to ignoring it. We also found the cost ratios (waiting-time to idle-time penalty), service time variation, and no-show pattern have a substantial influence on the block size of VSMBAS. Finally, we provide several practical implications based on our analysis.

Exploring healthcare providers’ experiences with specialty medication and limited distribution networks

Integrated health-system specialty pharmacies (IHSSP) have shown high medication access, adherence, and provider satisfaction. The goal of this study was to explore healthcare providers' experiences with specialty medications distributed via Limited Distribution Networks (LDN) that do not include IHSSPs. We investigated healthcare providers' perceived impact of LDNs on clinic workflow, clinical practice, and patient outcomes. Interviews and focus groups were conducted with fourteen healthcare providers from four outpatient specialty clinics at an academic health system with an IHSSP. Qualitative analysis using an iterative inductive/deductive approach of coded transcripts was used to identify themes. Participants discussed requirements and barriers to communicating with insurance providers, drug manufacturers, and external pharmacies; time and effort required to navigate LDNs and impact on workload and clinic workflow; financial awareness of medication costs and methods for communication about financial information with patients; and advocating for patients to ensure access to necessary therapy and avoid missed doses or treatment lapse. Participants reported barriers to navigating LDNs that can interfere with clinic workflow and patient care. IHSSPs may reduce clinic burden by helping patients access, afford, and remain on therapy.

N-acetylcysteine in the treatment of compulsive sexual behavior disorder: A case series

Although compulsive sexual behavior disorder (CSBD) is a relatively common disorder with an estimated prevalence of at least 3%, clinicians currently have limited evidence and no FDA-approved drugs to guide their treatment of this condition. N-acetylcysteine (NAC), an amino acid that seems to restore extracellular levels of glutamate in the nucleus accumbens, has previously demonstrated efficacy in treating multiple psychiatric disorders, including substance use disorders and putative behavioral addictions. However, no study has assessed the use of NAC (or any other glutamatergic agent, for that matter) in the treatment of CSBD. Here, we present data from a case series of 8 male patients with CSBD treated with NAC in routine clinical practice in a specialty outpatient clinic. Of these 8 patients, all of whom had previously been treated for CSBD with medications, therapy, or both, 5 had marked clinical improvement (>35% improvement on a modified version of Yale–Brown Obsessive Compulsive Scale) on NAC, and 3 showed minimal or no improvement (<15%). These findings suggest that NAC may be a potentially promising, well-tolerated treatment option for patients with CSBD, including those who have failed more traditional therapies.

Clinical Pharmacists' Contribution to Medication Reconciliation in Outpatient Specialty Clinics in Iran.

The majority of research in medication reconciliation has focused on the inpatient settings, and little is known about the outpatient settings, particularly in developing countries. As such, we conducted this study to evaluate direct clinical pharmacist involvement in medication reconciliation in outpatient specialty clinics in Iran. This prospective interventional study was conducted from September 2019 to February 2020 in a University-affiliated clinic in Iran. For 196 patients over 18 years of age who were scheduled for an appointment with a physician, medication reconciliation intervention was carried out by a clinical pharmacist. The number and type of unintentional discrepancies, their potential harm to the patients, their correlation with the patients' demographic and clinical characteristics, and the number of accepted recommendations upon the unintentional discrepancies by the clinicians were assessed and recorded. Additionally, patients' understanding of any change made to their current medication regimen was also assessed. In total, 57.14% of patients had at least one or more unintentional medication discrepancies, with an overall rate of 1.51 (±0.62) per patient. This is while the patient understanding of their medication changes was inadequate in a significant proportion of the study patients (62.2%). Patients with older ages, lower educational levels, and a higher number of medications and comorbidities were at a higher risk of having unintentional discrepancies. The most common type of unintentional discrepancy was the omission of a drug, and almost half of the reconciliation errors might have had the potential to cause moderate or severe harm to the patient. From 145 recommendations suggested by the clinical pharmacist upon unintentional discrepancies, 131 cases (90.34%) were accepted and implemented by the clinicians. These findings further support the need for conducting medication reconciliation in outpatient settings to identify discrepancies and enhance the safety of patient medication use.

Organization-level variation in therapists' attitudes toward and use of measurement-based care.

Despite significant interest in improving behavioral health therapists' implementation of measurement-based care (MBC)-and widespread acknowledgment of the potential importance of organization-level determinants-little is known about the extent to which therapists' use of, and attitudes toward, MBC vary across and within provider organizations or the multilevel factors that predict this variation. Data were collected from 177 therapists delivering psychotherapy to youth in 21 specialty outpatient clinics in the USA. Primary outcomes were use of MBC for progress monitoring and treatment modification, measured by the nationally-normed Current Assessment of Practice Evaluation-Revised. Secondary outcomes were therapist attitudes towards MBC. Linear multilevel regression models tested the association of theory-informed clinic and therapist characteristics with these outcomes. Use of MBC varied significantly across clinics, with means on progress monitoring ranging from values at the 25th to 93rd percentiles and means on treatment modification ranging from the 18th to 71st percentiles. At the clinic level, the most robust predictor of both outcomes was clinic climate for evidence-based practice implementation; at the therapist level, the most robust predictors were: attitudes regarding practicality, exposure to MBC in graduate training, and prior experience with MBC. Attitudes were most consistently related to clinic climate for evidence-based practice implementation, exposure to MBC in graduate training, and prior experience with MBC. There is important variation in therapists' attitudes toward and use of MBC across clinics. Implementation strategies that target clinic climate for evidence-based practice implementation, graduate training, and practicality may enhance MBC implementation in behavioral health.

Late-manifestation of attention-deficit/hyperactivity disorder in older adults: an observational study

BackgroundThe age of attention-deficit/hyperactivity disorder onset is usually during the first 12 years of life; however, there have been recent reports of late-onset attention-deficit/hyperactivity disorder. These reports have been limited to that of young adults, and details in older adults remain unknown. As such, we had previously presented the first case report of “very” late-onset attention-deficit/hyperactivity disorder, wherein the symptoms presented in senile age. In this observational study, we aimed to investigate the prevalence and clinical features of such attention-deficit/hyperactivity disorders in older adults visiting our dementia clinic.MethodsFour hundred forty-six consecutive patients visiting our specialty outpatient clinic for dementia during the 2-year period from April 1, 2015 to March 31, 2017 were included in this study. First, the patients were examined for the presence or absence of dementia in our specialty outpatient clinic for dementia. Those not diagnosed with dementia were examined for the presence or absence of attention-deficit/hyperactivity disorder in our specialty outpatient clinic for developmental disorders. Finally, these patients who were diagnosed with attention-deficit/hyperactivity disorder were investigated in detail to clarify their clinical characteristics.ResultsOf 446 patients (246 women and 200 men), 7 patients were finally diagnosed with attention-deficit/hyperactivity disorder. Although these 7 patients were initially suspected to have Alzheimer’s disease (considering their age, 6 of these 7 patients were suspected to have early onset Alzheimer’s disease), it was found that these symptoms were due to attention-deficit/hyperactivity disorder. These patients had four characteristics in common: (1) they were significantly younger than the complete study population; (2) they predominantly showed inattention-related symptoms; (3) they showed latent manifestation; and (4) they experienced a stressful life event before manifestation.ConclusionsOur previous case report suggested that very late-onset attention-deficit/hyperactivity disorder patients could be incorrectly diagnosed with dementia. In this observational study, 1.6% of patients who were initially suspected of having dementia were actually diagnosed with attention-deficit/hyperactivity disorder. This study also showed that the “late-onset” described in our previous report would be better described as “late-manifestation.” A clinician should consider late-manifestation of attention-deficit/hyperactivity disorder in the differential diagnosis when encountering dementia patients, especially early onset Alzheimer’s disease.

Analysis of Race and Sex Bias in the Autism Diagnostic Observation Schedule (ADOS-2)

There are long-standing disparities in the prevalence of autism spectrum disorder (ASD) across race and sex. Surprisingly, few studies have examined whether these disparities arise partially out of systematic biases in the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), the reference standard measure of ASD. To examine differential item functioning (DIF) of ADOS-2 items across sex and race. This is a cross-sectional study of children who were evaluated for ASD between 2014 and 2020 at a specialty outpatient clinic located in the Mid-Atlantic region of the US. Data were analyzed from July 2021 to February 2022. Child race (Black/African American vs White) and sex (female vs male). Item-level biases across ADOS-2 harmonized algorithm items, including social affect (SA; 10 items) and repetitive/restricted behaviors (RRBs; 4 items), were evaluated across 3 modules. Measurement bias was identified by examining DIF and differential test functioning (DTF), within a graded response, item response theory framework. Statistical significance was determined by a likelihood ratio χ2 test, and a series of metrics was used to examine the magnitude of DIF and DTF. A total of 6269 children (mean [SD] age, 6.77 [3.27] years; 1619 Black/African American [25.9%], 3151 White [50.3%], and 4970 male [79.4%]), were included in this study. Overall, 16 of 140 ADOS-2 diagnostic items (11%) had a significant DIF. For race, 8 items had a significant DIF, 6 of which involved SA. No single item showed DIF consistently across all modules. Most items with DIF had greater difficulty and poorer discrimination in Black/African American children compared with White children. For sex, 5 items showed significant DIF. DIF was split across SA and RRB. However, hand mannerisms evidenced DIF across all 5 algorithms, with generally greater difficulty. The magnitude of DIF was only moderate to large for 2 items: hand mannerisms (among female children) and repetitive interests (among Black/African American children). The overall estimated effect of DIF on total DTF was not large. These findings suggest that the ADOS-2 does not have widespread systematic measurement bias across race or sex. However, the findings raise some concerns around underdetection that warrant further research.

Memory Perfectionism is Associated with Persistent Memory Complaints after Concussion.

The etiology of persistent memory complaints after concussion is poorly understood. Memory perfectionism (highly valuing memory ability and intolerance of minor memory lapses) may help explain why some people report persistent subjective memory problems in the absence of corresponding objective memory impairment. This study investigated the relationship between memory perfectionism and persistent memory complaints after concussion. Secondary analysis of baseline data from a randomized controlled trial. Adults (N = 77; 61% women) with persistent symptoms following concussion were recruited from outpatient specialty clinics. Participants completed the National Institutes of Health Toolbox Cognition Battery, Test of Memory Malingering-Trial 1, and questionnaires measuring memory perfectionism (Metamemory in Adulthood-Achievement subscale), forgetfulness and other postconcussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), and depression (Patient Health Questionnaire-2) at M = 17.8weeks postinjury. Patients with versus without severe memory complaints (based on the RPQ) were compared. Memory perfectionism was associated cross-sectionally with severe memory complaint, after controlling for objective memory ability, overall cognitive ability, and depression (95% confidence interval for odds ratio = 1.11-1.40). Sensitivity analyses showed that this relationship did not depend on use of specific objective memory tests nor on inclusion of participants who failed performance validity testing. In a control comparison to test the specificity of identified relationships, memory perfectionism was not associated with severe fatigue (95% confidence interval for odds ratio = 0.91-1.07). Memory perfectionism may be a risk factor for persistent memory symptoms after concussion, with potential relevance to the spectrum of functional cognitive disorders more broadly.

Designing an interprofessional dementia specialty clinic: Conceptualization and evaluation of a patient-centered model

ABSTRACT The need for blueprints to design specialty care interprofessional collaboration (IPC) models is urgent, given the expanding aging population and current challenges in dementia diagnosis and treatment. We describe key steps creating an interprofessional outpatient dementia specialty clinic, efforts to sustain the model, and evaluation of interprofessional effectiveness and clinician satisfaction. The conception for the Comprehensive Memory Center was informed by qualitative research methodologies including focus groups, interviews, and literature reviews. Quantitative evaluation included satisfaction surveys and team effectiveness measures. The IPC model diverges from typical dementia practices through its interprofessional team, visit structure, approach to decision-making, in-house services, and community collaborations. Team retreats and workshops helped build clinician knowledge of interprofessional values and practices to sustain the IPC model. In the first 3.5 years, we served nearly 750 patients and their caregivers. Team evaluation results revealed that increased access to consultation and sharing the workload and emotional burden were beneficial. The majority of team members preferred the IPC model to traditional models of clinical care.

Fibrillar Collagen Variants in Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized nonatherosclerotic cause of acute myocardial infarction enriched among individuals with early-onset myocardial infarction but is of unclear etiology. To assess which genes contribute to the development of SCAD. To prioritize genes influencing risk for SCAD, whole-exome sequencing was performed among individuals with SCAD in the discovery and replication cohorts from a tertiary care hospital outpatient specialty clinic, and gene set enrichment analyses were also performed for disruptive coding variants. All patients were sequentially enrolled beginning July 2013. Aggregate prevalence of rare disruptive variants for prioritized gene sets was compared between individuals with SCAD with population-based controls comprising 46 468 UK Biobank participants with whole-exome sequencing. Complementary mice models were used for in vivo validation. Analysis took place between June 2020 and January 2021. The frequency and identity of rare genetic variants in individuals with SCAD. Of 130 patients, 109 (83.8%) were female (26 of 32 [81.2%] in the discovery cohort and 83 of 98 [84.7%] in the replication cohort) with mean (SD) age at first SCAD event of 48.41 (8.76) years in the discovery cohort and 47.74 (10.09) years in the replication cohort. Across all patients with SCAD, rare disruptive variants were found within 10 collagen genes (COL3A1, COL5A1, COL4A1, COL6A1, COL5A2, COL12A1, COL4A5, COL1A1, COL1A2, and COL27A1) were 17-fold (P = 1.5 × 10-9) enriched among individuals with SCAD compared with a background of 2506 constrained genes expressed in coronary artery. Furthermore, compared with individuals from the UK Biobank, individuals with SCAD were 1.75-fold (P = .04) more likely to carry disruptive rare variants within fibrillar collagen genes. Complementary mice models haploinsufficient for Col3a1 or Col5a1, the 2 most common collagen gene variants identified in SCAD cases, demonstrated increased risk of arterial dissection and increased size of arterial diameters especially in female mice, with resulting changes in collagen fibril organization and diameter. Unbiased gene discovery in patients with SCAD with independent human and murine validation highlights the role of the extracellular matrix dysfunction in SCAD.

Application of a Quality Improvement Process to Evaluate Self-Directed Therapy for Patients on a Waitlist in an Outpatient Anxiety Disorders Specialty Clinic

The demand for psychological services in the United States is higher than the available supply of qualified mental health professionals. As a result, there is a substantial need for low-cost interventions that are more accessible and amenable to scale-up independent of the availability of clinicians. Previous studies have found that self-directed bibliotherapy can be an effective intervention with minimal therapist contact. Using the Plan-Do-Study-Act (PDSA) improvement process framework, we implemented self-directed therapy in our outpatient anxiety disorders specialty clinic. We identified four self-directed therapy resources (two books and two smartphone apps) based on cognitive behavioral or acceptance and mindfulness principles. We conducted initial 30-minute billable bibliotherapy consultations with six patients on our waitlist, where we provided the rationale for self-guided treatment, introduced the four resources, helped the patient identify one resource to use, and answered any questions. Eight weeks later, we met with five of these patients for a second billable 30-minute consultation (one had already started individual therapy) and gathered information regarding feasibility and acceptability of these resources as well as helped the patient make continued or better use of the resource until beginning therapy. This case series suggests that self-directed interventions can be effectively implemented in this manner, though with mixed outcomes and effects on patients and their course of care. We describe improvements we intend to implement in future iterations of self-directed therapy.

Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation.

Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.

Cancer risk in patients with migraine: A population-based cohort study in Denmark.

The purpose of this study was to examine overall and site-specific cancer risk among individuals diagnosed with migraine compared with the general population. Current evidence regarding migraine and risk of cancer is sparse and inconclusive. We conducted a nationwide population-based cohort study with data collected routinely and prospectively from Danish population-based registries from 1995 to 2017. We computed the age- and sex-standardized incidence ratio (SIR) as the ratio of observed to expected cancers among patients diagnosed with migraine in the study population overall, and by encounter type of first diagnosis (inpatient, outpatient specialty clinic, and emergency department). Site-specific cancers were grouped according to etiology. We identified 72,826 patients with a first-time hospital migraine diagnosis. There were 3090 observed overall cancer cases among individuals diagnosed with migraine as compared with 3108 expected cases (SIR 0.99, 95% confidence interval [CI]: 0.96-1.03). The cumulative incidence of all cancers combined from 1995 to 2017 among those with a first-time migraine diagnosis was 9.47% (95% CI: 9.08-9.87). The SIRs for most cancers were consistent with absence of an association: 1.00 (95% CI: 0.94-1.06) for hormone-related cancers, 0.96 (95% CI: 0.88-1.03) for smoking-related cancers, 1.10 (95% CI: 0.98-1.24) for hematologic cancers, and 0.95 (95% CI: 0.85-1.06) for immune-related cancers. Exceptions were SIRs for gastrointestinal cancers (0.78, 95% CI: 0.70-0.87) and for cancers of neurological origin (1.57, 95% CI: 1.40-1.76). For most cancer groups, our results did not support an association with migraine. The exceptions were an increased risk for cancers of neurological origin and a decreased risk for gastrointestinal cancers. These findings may reflect a true difference in risk among individuals with migraine, or more plausibly they reflect other forces, such as differences in medication use, detection bias and reverse causation, or shared risk factors.

Clinical validation of the nursing diagnosis "Risk for delayed child development".

To validate clinically the risk factors of the nursing diagnosis "Risk for delayed child development". Cross-sectional quantitative study carried out in a specialty outpatient clinic and in family health units with 124 children. The data was collected through interviews with the children's guardians to investigate the risk factors for delay in child development. The tested risk factors affected 108 of the evaluated children (87.1%). In the accuracy tests, most specificity values were above 80% and sensitivity values were lower than 30%. Most risk factors had odds ratio >1, three of which were noteworthy: genetic disorder (OR = 38, p < 0.05) and congenital disorder (OR = 4.4, p < 0.05), among child-related aspects, and impaired cognitive development in parents (OR = 27, p < 0.05), among caregiver-related aspects. The study contributed to a refined diagnostic accuracy, identifying potential associated factors of the evaluated diagnosis.