Patient Unwillingness Research Articles

Buprenorphine with Bupivacaine 0.5% Heavy Versus Clonidine with Bupivacaine 0.5% Heavy Versus Bupivacaine 0.5% Heavy Alone in Patients Undergoing Total Abdominal Hysterectomy: A Comparative Study

Background and Aims: This research aimed to determine which of three spinal anaesthetic medication combinations—clonidine–bupivacaine, buprenorphine–bupivacaine and bupivacaine alone—is the most effective for total abdominal hysterectomy. Material and Methods: In this prospective study, approved by the Institutional Ethical Committee, 120 patients aged 35–60 years scheduled for elective total abdominal hysterectomy under spinal anaesthesia were included, following informed consent. Comprehensive pre-anaesthetic assessments, including detailed medical histories, clinical examinations and routine surgical investigations, were conducted. The study, spanning 24 months, utilised purposive sampling and a cross-sectional design. The inclusion criteria encompassed ASA I and II patients aged 35–60 years, undergoing elective total abdominal hysterectomy with a weight exceeding 45 kg, height over 150 cm, and valid informed consent. Exclusion criteria involved ASA Class III or higher, patient unwillingness for spinal anaesthesia, gross spinal deformities, bleeding diathesis, known allergy to the test drug, history of cardiac, respiratory, or central nervous system disease, hepatic or renal dysfunction and elevated intracranial pressure. Results: The onset time of sensory blockade was faster in the Bupivacaine + Buprenorphine group than in the Clonidine + Bupivacaine group, with the Bupivacaine group exhibiting the slowest onset. The Bupivacaine + Buprenorphine group had a significantly faster onset of motor block than the Clonidine + Bupivacaine and Bupivacaine groups. The total duration of motor block was shorter in both the Bupivacaine + Buprenorphine and Bupivacaine groups than in the Clonidine + Bupivacaine group. The Clonidine + Bupivacaine group showed higher incidences of bradycardia and hypotension than the other groups. The Bupivacaine + Buprenorphine group reported more side effects, including chest pain, cough, nausea and vomiting, than the other groups. Conclusion: This study found that spinal clonidine, in comparison to bupivacaine alone, gives better post-operative analgesia and sensory and motor blockage over a longer period of time.

The main principles of managing patients with Graves’ disease in clinical practice

BACKGROUND: Graves’ disease (GD) is a common cause of persistent thyrotoxicosis. In regions with adequate iodine intake, the incidence is 20–30 cases per 100,000 people. Modern treatment of GD includes antithyroid drugs, radioactive iodine therapy (RAI), and thyroidectomy. The choice of treatment strategy is based on the severity of thyrotoxicosis, the frequency of potential side effects, the availability of treatment options, and the likelihood of achieving sustained remission. Previous studies have demonstrated differences in approaches to diagnosis, treatment, and follow-up between countries and individual specialists.AIM: To conduct a survey on the current clinical practice of treating Graves’ disease in Russia.MATERIALS AND METHODS: An online survey was conducted among physicians in 2022-2023. The questions covered the principles of diagnosis, treatment, and dynamic observation of adult patients with Graves’ disease.RESULTS: The study involved 104 physicians of various specialties who treat patients with Graves’ disease. Approximately 99% of respondents chose the determination of thyroid-stimulating hormone receptor antibodies (TSHR-ab) to clarify the etiology of thyrotoxicosis, while only 60.6% of them chose thyroid scintigraphy. As the first-line treatment method, antithyroid drug therapy is chosen by 88.5%, while 13.5% of physicians use radioactive iodine therapy (RAI), and less than 1% of respondents refer patients to thyroidectomy. Thiamazole is most commonly used (99%), while propylthiouracil (PTU) is used in cases of allergy to thiamazole or during the first trimester of pregnancy. The «block-replace» scheme is preferred over the «block» scheme, with 72.1% compared to 28.8%, respectively. The majority of physicians (95.2%) initiate therapy with moderate doses of thiamazole (20–30 mg) and PTU (200–300 mg). Most physicians conduct dynamic monitoring of liver transaminase levels (57.7%) and complete blood count (78.8%). Conservative therapy is prescribed for a period of 12–18 months (88.5%) or up to 24 months (10.6%). Before discontinuing antithyroid drug therapy, 89.4% of respondents monitor thyroid hormone levels, 82.7% monitor TSHR-Ab levels, and 47.1% perform thyroid ultrasound. Repeat courses of conservative therapy are prescribed for up to 61.5% of respondents. Approximately 63.5% of surveyed physicians reported difficulties in referring patients for radical treatment due to a limited number of specialized institutions. Physicians cited patient unwillingness and the need to postpone pregnancy (81.6% and 24.3% respectively) as the main inhibitory factors for RAI. Thyroidectomy was associated with patient unwillingness (69.2%), as well as physician fear of laryngeal paralysis (48.1%) and postoperative hypoparathyroidism (49%).CONCLUSION: The results of the study demonstrated that physicians in their practice generally adhere to international recommendations for the treatment of Graves’ disease.

Marital status of a patient in the formation of his attitude to the organization of medical care provided on an outpatient basis

Introduction. The marital status of the patient is an important factor that affects his behavior, attitude to health and the healthcare system. Family relationships can have a positive or negative impact on the level of self-esteem, general psychological stability and readiness for treatment. For example, many people in stable relationships are more likely to monitor their health, visit doctors regularly and receive the necessary medical care. However, there are also negative aspects of marital status that can affect the patient's attitude to the healthcare system. For example, some patients may experience fear and embarrassment when seeking medical care without their spouse or partner. There are also cases when a patient's unwillingness to go to doctors is due to the fact that he does not want financial or emotional help from his family, but prefers to cope with his problems on his own. Thus, marital status is an important factor that must be taken into account when analyzing the attitude of patients to the healthcare system. Studying this problem can help medical institutions develop more effective service strategies and increase patient satisfaction.Materials and methods. For the analysis, 495 patients of medical organizations in Moscow were obtained by questioning. Two comparison groups were formed, the main group (the presence of marital relations) 292 people, the control group (the absence of marital relations) 203 people. Taking into account the nonparametric distribution of the primary data, the criterion of the reliability of differences χ2 was used to compare the groups, and the association coefficient was used to determine the dependence Ka.Results. According to the results of the analysis, taking into account the literature data, data on different approaches to the assessment of the medical care management system in patients with different family status were obtained.Conclusions. Family patients are more critical of the organization of the activities of individual departments of the polyclinic, but their criticism does not lead to a significant decrease in the overall assessment of the medical organization. Lonely patients make fewer specific claims, but reduce the overall assessment of the medical organization's activities.

Guide Flange Prosthesis: A Case Report

Patients who have undergone surgical hemi/segmental/subtotal mandibulectomy for various reasons with resulting mandibular deviation are given a guide flange. If secondary osseous grafting is planned, the doctor must wait for the graft, lesion, or radiotherapeutic effects to resolve. A definitive prosthesis can be planned only when the graft has been healed. During this time lag, the patient must be fitted with a prosthesis to rectify mandibular deviation caused by unilateral muscle strain. Furthermore, in some circumstances, a definitive prosthesis must be postponed due to bone grafting failure or the patient's unwillingness to undergo a second surgery. This clinical case report shows a mandibular guide flange prosthesis fabricated for a patient.

Reasons for Extraction of Permanent Teeth in Tertiary Care Hospital of Nepal

Introduction: Many studies conducted in different countries or geographic locations had reported different reasons as a major cause for permanent teeth extractions. Many patients report to our OPD for extraction and refuse other treatment options. This had led to early edentulism and decreased quality of life in our population.
 Methods: A sample size of 1000 who had tooth extracted in Nepalgunj Medical College Teaching Hospital, Kohalpur and consented to take part were included in this study from April 2019 to March 2022. Collected data were analyzed using Statistical Package for Social Sciences software (SPSS) Version 25 and Chi-square test was used to compare between different variables.
 Results: A total of 1000 (male 346(34.6%) and female 654(65.4%)) patients underwent extractions of 1306 teeth. The mean age of the patient was 44.27±17.488. Teeth were extracted most commonly in 4th decade of life and third molars were the most commonly extracted teeth. The most common reason for tooth loss is dental caries 939(71.9%). The most common cause for preventable tooth loss were Patient unwillingness to save the tooth 104(37.54%). Complications occurred in 61(4.7%) of cases intra-operatively and 21 (1.6%) cases postoperatively.
 Conclusions: Dental caries and its sequelae is the most common reason for extraction of all teeth and in all age group. Most patient visited clinic at the advanced stage where teeth cannot be saved. Failed endodontic treatment had also contributed for negative attitude towards teeth conservation among which majority of treatment has been performed by practitioner not registered in Nepal Medical Council.

Taxane-induced acute interstitial pneumonitis in patients with breast cancer and outcome of taxane rechallenge.

Background:Although rare, taxane-induced interstitial pneumonitis is a well-recognized toxicity following chemotherapy. Data on taxane rechallenge in patients who developed taxane-induced interstitial pneumonitis following chemotherapy are limited. Here, we share our experience of acute interstitial pneumonitis following taxane chemotherapy for breast cancer and its clinical outcome following steroids and subsequent rechallenge with taxanes in selected patients without residual lung abnormalities on imaging following steroid treatment.Objectives:To study the taxane-induced acute interstitial pneumonitis in patients with breast cancer receiving chemotherapy and outcome of taxane rechallenge in these patients.Materials and Methods:Patients with breast cancer who developed taxane-induced acute interstitial pneumonitis following chemotherapy either with paclitaxel or docetaxel were included.Results:Among 1240 patients with breast cancer, who received chemotherapy with either docetaxel or paclitaxel, 41 patients developed taxane-induced acute interstitial lung disease (ILD) during the study period. The interstitial pneumonitis was more seen with docetaxel. Among paclitaxel regimens, weekly schedules showed more cases of ILD than 2 weekly paclitaxel. After steroid pulse/maintenance treatment, complete resolution of lung abnormalities was seen in 76%, but residual interstitial pattern on imaging was noted in 24% of patients. Taxane rechallenge was done in 20 (49%) patients. Agents used were paclitaxel, nab-paclitaxel, or docetaxel. All rechallenged patients received short-course oral steroids for one week following taxane rechallenge as a safety measure. Rechallenge was not done in 51% either due to patient unwillingness for rechallenge (27%) or patient with residual interstitial pattern on imaging (24%). None of the patients experienced any recurrence of pneumonitis or any mortality following taxane rechallenge.Conclusion:Acute interstitial pneumonitis is a well-known toxicity following taxanes in breast cancer and taxane rechallenge is an option in those patients without any residual pneumonitis following steroid pulse/maintenance. We also advise short-course oral steroids for 1 week following taxane rechallenge as a safety measure. We strongly do not recommend rechallenge in patients with residual lung abnormalities after steroids.

Guideline based knowledge and practice of physicians in the management of COPD in a low- to middle-income country.

BackgroundChronic obstructive pulmonary disease (COPD) is the third leading cause of death, with 80% of the total death occurring in low‐ to middle‐income countries (LMICs). Nepal is one of the LMIC; COPD is a highly prevalent and significant public health issue often underdiagnosed. Medical physicians' good knowledge and practice to diagnose and treat COPD can help reduce the disease burden.ObjectivesTo determine the level of knowledge, practice and factors influencing the practice of physicians regarding COPD management based on GOLD guidelines.DesignA cross‐sectional descriptive study using a structured questionnaire was conducted among medical physicians working in Bagmati and Gandaki province of Nepal. Out of total scores, physicians knowledge and practice were graded according to Bloom's original cut‐off point for good (≥80%), satisfactory (60%–78%) and poor (<60%).ResultA total of 152 medical physicians participated in this study. Out of the possible total score 20, the mean score on knowledge was 17.8 ± 2.4, and out of possible total score eight, the mean score on practice was 5.3 ± 1.3. The correlation test between total knowledge and practice scores showed r = 0.18 and p value <0.02. The most selected factors hindering the appropriate management of COPD was lack of patient follow up and lack of professional training in COPD. Other factors included patient unwillingness to discuss smoking quit plan, lack of screening tool, unavailability of spirometry and physician unawareness of available medicine to treat COPD.ConclusionDespite physicians having good knowledge in COPD, the practice in COPD management is below guideline‐recommended. There is a significant, very low positive correlation between total knowledge score and practice score. Proper COPD training to physicians, disease awareness among patients, easy availability of diagnostic equipment and medication can help improve physicians' practice and appropriately manage COPD patients.

Telehealth during COVID-19 pandemic era: a systematic review

&lt;abstract&gt;&lt;sec&gt; &lt;title&gt;Background&lt;/title&gt; &lt;p&gt;Across the globe, the coronavirus (COVID-19) pandemic has altered the delivery of healthcare services as patients must maintain their distance from caregivers, and still receive medical treatment. This has triggered a necessity for exploring means which minimizes the physical gap between patients and healthcare givers while offering health care and ensuring high medical protection at a reduced risk of exposure. Even though telehealth services are no replacement for conventional healthcare, its' usefulness in the coronavirus (COVID-19) pandemic is immense.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Objective&lt;/title&gt; &lt;p&gt;This research reviews the ardent utilization, barriers and recommendations with telehealth services for healthcare delivery during the COVID-19 pandemic.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Methods&lt;/title&gt; &lt;p&gt;An assessment of literature in five large digital databases; PubMed, Science Direct, Sage Pub, ProQuest, and Google Scholar was conducted. Inclusion criteria included studies defining telehealth/telemedicine, utilization, barriers and recommendations during the COVID-19 pandemic from January 2020 to July 2021, written in English and published in peer-reviewed journals. Two reviewers independently assessed search results, extracted data, and assessed the quality of the included studies. Narrative synthesis was undertaken to summarize and report the findings.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Results&lt;/title&gt; &lt;p&gt;Overall, the study discoveries which are most commonly stated as impediments for telehealth services' full utilization between patients and physicians beyond the scope of typical medical confinement are: infrastructure and internet access (20.00%), data privacy and security (13.33%), digital literacy (13.33%), reimbursement and liability (10.00%), and clinician and patient's unwillingness (6.67%).&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Conclusions&lt;/title&gt; &lt;p&gt;The intrusion of coronavirus has accelerated the transition to telehealth services in healthcare delivery, but it has also provided a unique chance to demonstrate the critical role that telehealth can play in ensuring that people of all races, ethnicities, and communities receive high-quality treatment (justice). Healthcare professionals should emphasize the effectiveness of telehealth services as an alternate healthcare delivery method in promoting healthcare to all populace.&lt;/p&gt; &lt;/sec&gt;&lt;/abstract&gt;

Referral of patients with chronic obstructive pulmonary disease to pulmonary rehabilitation from primary care: A local survey of GPs and practice nurses

Aim To gain an understanding of the referral practices of local general practitioners (GPs) and practice nurses (PNs) to a local pulmonary rehabilitation (PR) programme in order to improve referral rates of patients with chronic obstructive pulmonary disease (COPD). Methods The study involved a cross-sectional survey of local GP and PNs from 16 GP practices within a local health and social care trust. The survey was distributed electronically and in hard copy form to GP practices and a 1-month period was provided to complete the survey. Inclusion/exclusion criteria GPs and PNs who review patients with COPD were eligible to complete the survey. Outcome measures The study reports on descriptive statistics for perceived referral rates to PR, knowledge of PR referral process within the local area, service user barriers, referral barriers and strategies to improve referral. Inferential statistics were used to determine if differences existed between GPs and PNs with regards MRC questioning and PR education. Results The survey was distributed to a total of 70 people, with responses received from 13 general practitioners (GPs) and 11 practice nurses. The overall response rate for the survey was 34%, with a GP response rate of 23% versus a PN response rate of 79%. 83% percent (n = 20) of respondents estimated they referred &lt;50% and 17% (n = 4) did not refer any COPD patients to PR. The number of PNs who reported that they question service-users around exertional breathlessness and educate around the benefits of PR was significantly higher than participating GPs (p &lt;0.05). 63% (n = 15) of respondents felt that the principal barrier to PR referral was patient unwillingness/refusal to attend. 29% (n = 7) of respondents felt that information leaflets/posters would improve referral rates to PR. Conclusions In this local survey referral from primary care to PR in the COPD population was underutilised by clinicians. PNs reported that they were more likely than GPs to explore patient’s exertional breathlessness and to educate patients regarding the benefits of PR. Respondents perceived that patient unwillingness to attend PR was the primary barrier however practitioner referral barriers in the form of time constraints were also cited. Respondents also cited a perceived lack of patient understanding of the benefits of PR as a factor affecting PR attendance.

Are nurses utilizing the non-pharmacological pain management techniques in surgical wards?

The non-pharmacological pain management therapies have a valuable effect in managing moderate to mild pain intensity, especially if demonstrated in the pre-operative phase. The study aimed to explore the nurses’ practice toward using non-pharmacological pain management techniques in surgical wards. In a cross-sectional research design, a convenient sample of 47 nurses in the surgical wards in Egyptian hospital (Third Level) participated in the study. Data gathered using modified Non-pharmacological Methods Questionnaire. Results of the study indicated that nurse’s perception regarding applying the cognitive-behavioral methods as a distraction and Positive reinforcement techniques were more common (68.1%,53.2%), whereas most of them used emotional support (93.6%) and preferred to demonstrate physical methods. Meanwhile, nurses addressed the barriers to apply nonpharmacological pain management as lack of time, patient unwillingness, and patients’ health beliefs. Nevertheless, nurses reported the non-pharmacological pain management is less expensive and has fewer side effects than medication and can demonstrated post-discharge. Nurses play a key role in applying effective and different non-pharmacological therapies in surgical wards. Thus, nurses should be encouraged to demonstrate the non-pharmacological pain management therapies with patients undergoing surgical procedures.

DISTANCE FROM HOSPITAL DOES NOT REDUCE UTILIZATION OF FERTILITY PRESERVATION IN MEN

Fertility preservation (FP) is underutilized in adult, young adult, and adolescent males with cancer or other diseases requiring gonadotoxic therapies. Two possible contributing reasons for low referral rates are perceived lack of access or patient unwillingness to travel to distant FP centers. We sought to evaluate whether patient distance from FP center affected rates of providing a semen analysis after referral.

Barriers and facilitators to patient engagement in patient safety from patients and healthcare professionals' perspectives: A systematic review and meta-synthesis.

To explore patients' and healthcare professionals' (HCPs) perceived barriers and facilitators to patient engagement in patient safety. We conducted a systematic review and meta-synthesis from five computerized databases, including PubMed/MEDLINE, Embase, Web of Science, Scopus and PsycINFO, as well as grey literature and reference lists of included studies. Data were last searched in December 2019 with no limitation on the year of publication. Qualitative and Mix-methods studies that explored HCPs' and patients' perceptions of barriers and facilitators to patient engagement in patient safety were included. Two authors independently screened the titles and the abstracts of studies. Next, the full texts of the screened studies were reviewed by two authors. Potential discrepancies were resolved by consensus with a third author. The Mixed Methods Appraisal Tool was used for quality appraisal. Thematic analysis was used to synthesize results. Nineteen studies out of 2616 were included in this systematic review. Themes related to barriers included: patient unwillingness, HCPs' unwillingness, and inadequate infrastructures. Themes related to facilitators were: encouraging patients, sharing information with patients, establishing trustful relationship, establishing patient-centred care and improving organizational resources. Patients have an active role in improving their safety. Strategies are required to address barriers that hinder or prevent patient engagement and create capacity and facilitate action.

Community pharmacists\u2019 perceptions on providing fall prevention services: a mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements.

Use of the geriatric assessment in clinical practice in Mexico: A survey of cancer providers.

e24013 Background: Despite the growing burden of cancer in older adults in Mexico, it is unknown how many cancer care providers in Mexico use information obtained through a geriatric assessment (GA) and/or geriatric oncology principles in their everyday clinical practice. Methods: We administered a cross-sectional survey to oncology providers in Mexico via the Mexican Society of Oncology mailing list (n = 1240). The survey included questions on demographics, awareness about geriatric oncology principles, and the use of the GA and other geriatric clinical tools. The primary outcome was to estimate the proportion of providers using GA tools through the question: “For your patients ≥65 years, do you perform a multidimensional geriatric assessment using validated tools?”. We hypothesized that ≤10% of respondents would give a positive answer. We used descriptive statistics and X2 tests to compare groups of respondents. Results: We obtained 196 answers (response rate 15.8%). 121 (62%) respondents were male; median age 42. 98 (50%) were surgical oncologists, 59 (30%) medical oncologists, and 38 (19%) radiation oncologists. Median time in practice was 8 years, with 39% practicing in Mexico City. A third had their practice at a public institution, 26% at a private institution, and 38% in both. The proportion of patients aged 65-79 and ≥80 seen on an average clinic day by the respondents was 30% and 10%, respectively. 121 (62%) reported having a geriatrician available at their practice site. 37 respondents (19%) reported using validated GA tools to evaluate older adults with cancer in their practice. The proportion of respondents who evaluated each GA domain is shown in Table 1. Male respondents (p=0.03), medical oncologists (p&lt;0.01), and those with a less busy practice (≤10 patients/day) (p=0.01) were more likely to use validated tools to perform a GA. Regarding barriers for implementing GA, 37% reported lack of time, 49% lack of qualified personnel, 44% lack of knowledge of geriatric tools, 6% patient unwillingness to undergo a GA, and 8% prohibitive cost. Only 17 (9%) thought that information obtained through a GA would not lead to practice changes. Conclusions: According to our survey, the proportion of Mexican oncology providers using validated tools to perform a GA is 19%, which is higher than expected. Some GA domains, such as comorbidity and functional status, were commonly assessed, while others, such as fall history, were seldom evaluated. Common barriers for GA implementation were lack of qualified personnel and of knowledge about geriatric tools. We plan to further explore these barriers and potential facilitators through focused interviews in order to guide future interventions.[Table: see text]

Diagnosis of pelvic inflammatory disease and barriers to conducting pelvic examinations in Australian general practice: findings from an online survey.

An online survey investigating Australian GPs' chlamydia management, including PID diagnosis, was conducted in 2019. From 323 respondents, 85.8% (n = 277) answered multiple-choice questions about PID and 74.6% (n = 241) answered a free-text question about barriers to conducting pelvic examinations. Using multivariable logistic regression, we identified factors associated with conducting pelvic examinations. Barriers to performing pelvic examinations were explored using thematic analysis. Most GPs indicated that they routinely ask female patients with a sexually transmissible infection about PID symptoms, including pelvic pain (86.2%), abnormal vaginal discharge (95.3%), abnormal vaginal bleeding (89.5%), and dyspareunia (79.6%). Over half reported routinely conducting speculum (69.0%) and bimanual pelvic (55.3%) examinations for women reporting pelvic pain. Female GPs were more likely to perform speculum [adjusted odds ratio (AOR) 4.6; 95%CI: 2.6-8.2] and bimanual pelvic examinations (AOR 3.7; 95%CI: 2.1-6.5). GPs with additional sexual health training were more likely to routinely perform speculum (AOR 2.2; 95%CI: 1.1-4.2) and bimanual pelvic examinations (AOR 2.1; 95%CI: 1.2-3.7). Barriers to pelvic examinations were patient unwillingness and/or refusal, GP gender, patient health-related factors, time pressures, and GP reluctance. Although GPs typically ask about PID symptoms when managing patients with chlamydia, they are not consistently able or willing to perform pelvic examinations to support a diagnosis, potentially reducing capacity to diagnose PID.

A prospective study on the incidence of postponed time-sensitive urological procedures during the SARS-CoV-2 pandemic due to patient preference.

BackgroundThe risk of acquiring perioperative SARS-CoV-2 infection is concerning for surgeons and patients.AimsIn this study, we investigate the incidence of postponed, medically necessary, time-sensitive urological procedures due to a patient’s unwillingness to proceed to a recommended surgical intervention during the first phase of the SARS-CoV-2 pandemic.MethodsWe prospectively monitored all patients undergoing elective urological surgery during the initial phase of the SARS-CoV-2 pandemic. The primary outcome measurement was incidence of postponed, medically necessary, urological procedures due to the patient’s decision not to proceed to a recommended urological intervention (16th of March–5th of June 2020). The secondary outcome measurements were the type of delayed procedure and duration of postponement.ResultsDuring the initial 12-week period of the SARS-CoV-2 pandemic, 155 elective urgent urological procedures were scheduled after pre-operative SARS-CoV-2 screening. In total, 140 procedures were performed and 15 (10%) patients intentionally delayed their urological procedure due to the perceived risk of acquiring nosocomial perioperative SARS-CoV-2 infection. The duration for procedural delays is currently 42 ± 23 (range: 15–80) days. The most frequently postponed procedures among patients unwilling to proceed to surgery are urgent endourological procedures due to symptomatic urolithiasis (n = 7/15).ConclusionsThe incidence for patients postponing urological procedures due to the risk of acquiring nosocomial SARS-CoV-2 is 10%. Endourological procedures for urolithiasis are the most frequently postponed procedures by patients. This study demonstrates that a subset of patients will decline urgent urological surgery during the SARS-CoV-2 pandemic.

To Drill or Not to Drill: Management of Endodontic Emergencies and In-Process Patients during the COVID-19 Pandemic

IntroductionDental professionals are at high risk of contracting coronavirus disease 2019 (COVID-19) infection because of their scope of practice with aerosol-generating procedures. Recommendation by the Centers for Disease Control and Prevention to suspend elective dental procedures and avoid aerosol-generating procedures posed significant challenges in the management of patients presenting with endodontic emergencies and uncertainty of outcomes for endodontic procedures initiated, but not completed, before shutdown. The purpose of this study was to evaluate the success of palliative care on endodontic emergencies during the COVID-19 pandemic and to evaluate the stability of teeth with long-term Ca(OH)2 placement because of delays in treatment completion. MethodsPatients presenting for endodontic emergencies during COVID-19 Shelter-in-Place orders received palliative care, including pharmacologic therapy and/or non–aerosol-generating procedural interventions. Part I of the study evaluated the effectiveness of palliative care, and need for aerosol-generating procedures or extractions was quantified. Part II of the study evaluated survivability and rate of adverse events for teeth that received partial or full root canal debridement and placement of calcium hydroxide before shutdown. ResultsPart I: Twenty-one patients presented with endodontic emergencies in 25 teeth during statewide shutdown. At a follow-up rate of 96%, 83% of endodontic emergencies required no further treatment or intervention after palliative care. Part II: Thirty-one teeth had received partial or full root canal debridement before statewide shutdown. Mean time to complete treatment was 13 weeks. At a recall rate of 100%, 77% of teeth did not experience any adverse events due to delays in treatment completion. The most common adverse event was a fractured provisional restoration (13%), followed by painful and/or infectious flare-up (6.4%), which were managed appropriately and therefore seemed successful. Only 1 tooth was fractured and nonrestorable (3%), leading to a failed outcome of tooth extraction. The remaining 4 outcome failures (13%) were due to patient unwillingness to undergo school-mandated COVID testing or patient unwillingness to continue treatment because of perceived risk of COVID infection. ConclusionsPalliative care for management of endodontic emergencies is a successful option when aerosol-generating procedures are restricted. This treatment approach may be considered in an effort to reduce risk of transmission of COVID-19 infection during subsequent shutdowns. Prolonged Ca(OH)2 medicament because of COVID-19 related delays in treatment completion appeared to have minimal effect on survival of teeth.

Willingness of people with Type 2 diabetes to start insulin therapy: Evidence from the South African Tshwane Insulin Project (TIP)

AimsTo determine factors associated with ‘hypothetical willingness’ to start insulin among people with Type 2 diabetes (T2DM). MethodsA quantitative cross-sectional study with insulin-naïve T2DM patients at 23 primary care facilities in the Tshwane Metropolitan Municipality. Data collected included demographic and clinical data, willingness to start insulin, attitudes and barriers to insulin therapy. Factors associated with unwillingness to start insulin therapy were explored using a multivariable logistic regression model. ResultsOf 468 T2DM study patients (mean age 57.2, SD = 11.3 years), more than half (51.9%) expressed unwillingness to starting insulin therapy. Unwillingness was associated with negative attitudes (OR = 1.32, 95% CI = 1.12–1.55, p = 0.001) and reluctance (OR = 1.41, 95% CI = 1.27–1.57, p < 0.001) rather than age, sex, education or diabetes duration. The strongest reasons for patient unwillingness were injection anxieties, fear of needles, insufficient knowledge of insulin, feeling unable to cope with insulin and concerns about out-of-pocket costs. ConclusionsThe prospect of insulin therapy disturbs patients’ sense of self and their psychological wellbeing. The high prevalence of psychological insulin resistance among these T2DM patients needs to be addressed for effective diabetes management.

Radiofrequency Ablation on Autonomously Functioning Thyroid Nodules: A Critical Appraisal and Review of the Literature.

Background: Thyroid nodules are an extremely common occurrence, as their prevalence in the general population is estimated to range between 50 and 70%. Some of these nodules are autonomously functioning such that they can cause hyperthyroidism over time. In this case, surgery and radioiodine represent the standard of care. Nevertheless, patients might have contraindications or be unwilling to undergo these treatments. Minimally-invasive ultrasound-guided techniques, such as laser and radiofrequency ablation (RFA), have been recently introduced into clinical practice as an alternative treatment for symptomatic benign thyroid nodules. Due to their efficacy and tolerability, these techniques have become increasingly available and their usage has been extended also to autonomously functioning thyroid nodules (AFTN).Methods: In this narrative review, we will describe the studies reporting the therapeutic effects of RFA on AFTN, the studies reporting how RFA compares to the other treatment modalities, as well as the current indications for the use of RFA in patients with AFTN. For this purpose, a comprehensive literature search was independently conducted by three investigators on PubMed, EMBASE, and the Cochrane Library from inception up to February 2020 to identify published articles concerning the effects of RFA on AFTN.Results and Conclusions: Current consensus statements and guidelines support the notion that RFA should be regarded as a first-line therapy for non-functioning benign thyroid nodules, while it remains a valid second-line option for AFTN treatment in case of contraindications or patient unwillingness to undergo surgery or radioiodine.

Mobile apps: Breaking barriers to early cancer detection in underserved communities.

2065 Background: Despite being potentially curable with early detection and timely treatment, breast (BC) and cervical cancers (CC) remain leading causes of death for Colombian women. Lack of cancer screening education, tedious administrative processes, and geographical limitations hinder early cancer detection. Today, technological tools permeate all levels of society and could gather data for user risk stratification, deliver clear and customized information, and help with care coordination, tracking, and addressing communication, transportation, and financial barriers. We aimed to assess the effectiveness of a free mobile application (mApp) to reach women, understand misconceptions about cancer screening, identify users at risk for BC and CC, and coordinate screening tests in Cali, Colombia. Methods: The mApp, Ámate, was developed over 4 months and advertised to women (≥14 years) in waiting rooms of 4 healthcare facilities in Cali, Colombia for 23 months. Ámate used educational, evaluative, and risk factor questions followed by brief explanations to assess the population’s knowledge, educate users on BC and CC, and identify users in need of BC and/or CC screenings. Correct answers yielded points redeemable for cellular data. Women who required screening were subsequently navigated to a healthcare provider and enrolled in the national cancer program. Results: From August 2017-August 2019, 1,043 women from Cali downloaded Ámate and answered all questions. Misconceptions about BC included beliefs that BC can be prevented (87%), obesity does not increase the risk of BC (49%), deodorant causes BC (17%), and only women with a relative with BC can get BC (16%). For CC, misconceptions included that pap smears should not be performed while sexually active (64%), vaginal pain is an early sign of CC (44%), and only women contract HPV (33%). Overall, 31.5% (329) were identified as at-risk and needed a mammogram and/or pap smear. So far, 30% (98) were successfully navigated and completed their recommended screening test(s). Barriers to enrollment in these programs included patient unwillingness, using fake contact information, limited available appointments, and denied access due to healthcare coverage. Conclusions: Ámate is an accessible tool that identifies women at-risk for breast and cervical cancer and detects barriers to early cancer detection. Administrative obstacles exist and must be addressed to improve early cancer detection/screening. Ámate is currently being tested in other areas of Colombia and may be useful in other underserved countries.