Practice Consultations Research Articles

Delayed Mandibular Hematoma Following Selective Androgen Receptor Modulator (SARM) Usage.

Selective androgen receptor modulators (SARMs) have been used for various conditions since the late 1990s. Functioning similarly to testosterone, they are used to improve sexual function, skeletal muscle mass, and bone mass, and exhibit other favorable physiological effects. While SARMs are associated with side effects varying from edema to polycythemia, the biggest concern is their lack of regulation, as they are not FDA approved. Recent findings suggest the use of SARMs for reducing breast cancer tumor growth and is being explored for its effects in AR+/HER2-/ER+ advanced breast cancer development. Given the potential for SARMs in breast cancer treatment, plastic surgeons must begin to consider navigating the use of SARMs in practice and preoperative consultations regarding SARM usage. In addition, SARMs' anticoagulative properties must be further examined. This case presents a delayed hematoma following treatment for maxillary hypoplasia. Our findings indicate that the patients' usage of SARMs is responsible for the postoperative complications.

Current Status of Neonatal Music Therapy Services Within the US

Abstract Over the past 30 years, music therapy services in the neonatal intensive care units (NICUs) have expanded, yet there is still limited literature available that captures current practice trends in this setting. The purpose of this paper was to obtain descriptive data about current demographics, consultation, and clinical practice trends in NICU music therapy clinical practice in the US. A questionnaire was sent to 9,222 Board-Certified Music Therapists. Those providing music therapy services in the NICU and choosing to participate (N = 87) completed the questionnaire. Results showed that a majority of music therapists working in the NICU who responded to the questionnaire have completed additional training to provide specialized services. Most NICU music therapists reported spending less than 20 hr a week on the unit and providing a variety of family-centered interventions to infants starting at 28 weeks postmenstrual age (PMA). Common diagnoses for referral besides prematurity were Neonatal Opioid Withdrawal Syndrome and Chronic Lung Disease. Music therapists are well integrated within treatment teams with a majority reporting collaborating and/or co–treating with other therapies and/or clinical staff.

Sources and content of advice sought by parents/guardians prior to emergency department attendance.

To describe sources of advice and the recommendations given to parents/guardians prior to attending ED with their child. This was a prospective observational study of patients presenting to two EDs of a multi-centre Victorian Health service in June 2016. Data collection involved surveying all parents/guardians attending paediatric ED during a 1-week period by trained research assistants. We determined the proportion of eligible respondents who sought advice before attending ED, the source of advice, and the type of advice provided. One thousand sixty-nine patients presented to ED over the 1-week period. There were 730 responses to the survey, of which 65% (477/730) had received a total of 620 recommendations prior to ED attendance. Seventy-six per cent (362/477) had received advice from a single source, 19% (90/477) had received advice from 2 sources, and 5% (25/477) from 3 or more sources. The most common sources of advice were general practice consultations (49%), friends/family (13.5%), and NURSE-ON-CALL (11%). Fifty-four per cent (335/620) of the recommendations were to attend ED immediately and 12% (77/620) were to attend if their child was getting worse. Most parents and guardians sought advice from a single source prior to attending an ED. The most common source of advice was consultation with a general practitioner and the most common recommendation was to attend ED immediately, or if their child's condition worsened.

Determining the role of remote consultations in general surgical practice in Scotland: a qualitative questionnaire-based study

INTRODUCTION Telemedicine consultations became widespread during the COVID-19 pandemic to deliver healthcare while minimising viral transmission. Research around establishing the role of remote appointments in general surgery outpatient clinics after the pandemic has not been undertaken. The aim of this study was to investigate views on remote consultations to determine this. METHODS Patients attending the adult general surgical outpatient clinic at Aberdeen Royal Infirmary between August 2021 and January 2022 as well as general surgeons from three neighbouring hospitals were invited to complete an anonymous questionnaire on the acceptability of remote and face-to-face (F2F) appointments in pre and postoperative scenarios. Differences in patients’ preferences between demographic groups, and between patients’ and surgeons’ views were analysed. RESULTS A total of 51 patients and 26 surgeons responded. Patients’ views differed depending on demographic parameters and the scenario. Patients and surgeons had similar views on preoperative consultations. Given the choice of telephone, video or F2F appointments, the F2F option was overall most popular. Patients and surgeons differed in their views on remote consultations following surgery and acute admissions. In some scenarios, young patients, those who lived in remote regions and those in employment/education preferred remote appointments. CONCLUSIONS While telemedicine is feasible and acceptable in general surgery clinics, there are differences in preferences between surgeons and patients. Patients’ preferences varied depending on their background, home circumstances and clinical context. Service provision should ensure that when remote consultations are available, patient preference is prioritised rather than surgeon ease.

Health symptoms and cosmetic silicone breast implants: A retrospective cohort study

BackgroundThere has been a growing concern about a possible causal relationship between silicone breast implants (SBIs) and health symptoms, often referred to as Breast Implant Illness. This study assessed the association between SBIs for cosmetic augmentation and health symptoms. MethodsRetrospective cohort study using data linkage with the Dutch Breast Implant Registry and Nivel Primary Care Database. A total of 688 women with cosmetic SBIs were age-matched with 1301 women without SBIs. The occurrence of thirteen health symptoms presented in general practice was assessed one year before implantation until three years after implantation. Comparisons were made regarding the number of symptoms and general practice consultations, both before and after implantation, and between the two groups. ResultsWomen with SBIs were more likely to experience three or more distinct health symptoms and a combination of multiple symptoms with multiple consultations during follow-up than women without SBIs (adjusted OR 1.44, 95% CI 1.06 to 1.96; adjusted OR 1.44, 95% CI 1.04 to 2.00, respectively). Women with SBIs also had a more than twice greater likelihood of these outcomes in the second year after implantation compared to one year before implantation (OR 2.13, 95% CI 1.27 to 3.57; OR 2.13, 95% CI 1.22 to 3.72, respectively). ConclusionsWomen with cosmetic SBIs had increased odds of health symptoms after implantation compared to before and to women without SBIs. These results suggest an association between health symptoms and cosmetic SBIs that needs further research to explore whether there is causality or residual confounding.

The impact of the COVID-19 pandemic on antibiotic prescription rates in out-of-hours primary care – a register-based study in Denmark

Background Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship. Aim To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group. Methods This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate). Results The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96–0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62–0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70–1.76). The decline in clinic consultations was largest for consultations involving children aged 0–10 years (RR = 0.53, 95%CI: 0.51–0.56). Conclusion Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

Reducing strain on primary healthcare systems through innovative models of care: the impact of direct access physiotherapy for musculoskeletal conditions—an interrupted time series analysis

ObjectivesTo evaluate the longitudinal impact of introducing a national, direct access physiotherapy model of care on the rates of primary and secondary care consultations for musculoskeletal (MSK) conditions.DesignInterrupted time series...

Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study protocol (TOGETHER 2).

General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs) providing clinical care to multiple patients at the same time. Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.

Evaluation of the Effectiveness of Virtual Telephone Consultations Against Traditional Face-to-Face Consultations in Spine Surgery Using an Objective Metric.

Coronavirus disease 2019 (COVID-19) proved to be a catalyst in the paradigm change from face-to-face (F2F) to virtual consultations in trauma and orthopaedics. This study evaluates the efficacy of telephone consultations versus F2F reviews in an elective spine clinic. In this retrospective study, the clinic lettersfrom elective spinal clinics were conducted over one month.Patients with lumbar spine pathology were included, divided into telephone and F2F groups, and further categorized into new referrals and follow-ups. The Ashford Clinic Letter Score (ACLS) was used to assess the efficacy of consultations. Results: Out of 126 spinal patients reviewed, 92 met the inclusion criteria. Of these, 47 were F2F and 45 were telephone consultations. The mean satisfaction scores for all patients were 7.60 for F2F and 7.42 for telephone consultations, with no significant difference (p=0.202). New patient satisfaction scores were 7.64 for F2F and 7.35 for telephone (p=0.284), and follow-up scores were 7.58 for F2F and 7.48 for telephone (p=0.530). The results showed that there was no difference between face-to-face and virtual consultations. Telephone consultations are nearly as effective as F2F consultations in elective spine clinics, particularly for follow-up patients. The findings support the viability of telemedicine as an economical and efficient alternative method instead of traditional F2F consultations in orthopaedic practice. Further research is needed to explore patient satisfaction and outcomes in other spinal pathologies and to optimise patient stratification for telemedicine.

Communication during telemedicine consultations in general practice: perspectives from general practitioners and their patients

BackgroundTelemedicine allows delivery of healthcare to occur between parties that are not in the same location. As telemedicine users are not co-present, effective communication methods are crucial to the delivery and reception of information. The aim of this study was to explore perspectives of general practitioners (GPs) and patients on the interactional components of telemedicine consultations.MethodsSemi-structured qualitative interviews were held with telemedicine users; 15 GPs and nine patients self-selected from a larger telemedicine study. Participants were asked about their preparation for telemedicine consultations, conducting telemedicine consultations and post-consultation activities. Deidentified transcripts from the interviews were analysed thematically.ResultsGPs and patients discussed factors they used to decide whether a consultation would be best conducted by telemedicine or in-person; the condition to be discussed, the existing doctor-patient relationship and whether physical examination was required. Participants also described how they prepared for their telemedicine consultations, gathering relevant documents, and reading previous notes. Participants described strategies they employed to optimise the telemedicine interaction; improving conversational flow and building rapport, as well as difficulties they experienced when trying to provide and receive care via telemedicine.ConclusionsPatient factors including health literacy and familiarity with technology affect the transfer of information shared during telemedicine consultations and consideration of these factors when choosing patients for telemedicine is required. Many GPs and patients have innate communication skills to effectively deliver and receive care through telemedicine. However, they may not be aware of these subconscious techniques to use to optimise telemedicine consultations. Communication training could be delivered to increase conversational flow, build rapport, and establish safety netting.

71 - Weight management discussion in real-world general practice consultations: A qualitative analysis in Australian primary care

71 - Weight management discussion in real-world general practice consultations: A qualitative analysis in Australian primary care

Annual incidence of general practice consultations related, according to the general practitioner, to bed bugs and description of cases, 2019-2020, France.

Bed bug infestations have been increasing worldwide since the 2000s. Their consequences for health range from skin reactions to major psychological distress. However, epidemiological data is still lacking. This study estimated the incidence of general practice consultations related to bed bugs in France and evaluated factors associated with repercussions on everyday life. We conducted a prospective observational study from March 2019 to April 2020 among 217 GPs in France. Annual and monthly GP consultations related to bed bugs were estimated from the reported cases. Descriptive analyses were performed, and factors associated with repercussions on everyday life were assessed using a logistic regression model. The annual incidence rate of GP consultations related to bed bugs was estimated at 109 per 100,000 inhabitants [95%CI: 92-126]. Bed bug-related consultations occurred in all regions, peaking in the summer. Moderate-to-severe repercussions on everyday life were reported by 39% of the patients. The associated factors with this level of repercussions were: having seen bed bugs (OR = 4.02 [95%CI: 1.6-10.73]), having lesions from scratching (OR = 5.25 [1.65-19.92]), having lesions on the head and the neck (OR = 3.97 [1.52-10.95]) and reporting psychological distress (OR = 6.79 [2.47-20.42]). This study provides new knowledge on GP consultations related to bed bugs in France. These data will help tailor public health programs to the population's needs, including information and training for primary healthcare professionals.

Discussions about physical activity in general practice: analysis of video-recorded consultations.

Background Clinical guidance recommends promotion of physical activity during general practice consultations. The frequency and content of physical activity discussions in UK general practice are poorly understood. Aim To explore the content of physical activity discussions during routine consultations between patients and general practitioners (GPs). Design and setting Secondary analysis of video-recorded UK general practice consultations from the One in a Million study. Methods We screened 294 consultation transcripts, identifying consultations that included or omitted physical activity advice when recommended by National Institute for Health and Care Excellence (NICE) guidance. We coded the content, quality and depth of advice provided by GPs. Results Physical activity was relevant to management according to clinical guidance in 175/294 (59.5%) consultations. In 64/175 (36.6%) of these consultations physical activity was discussed as part of clinical management and the depth of discussion was judged as 'meaningful' in 22 (12.6%). Whilst physical activity advice tended to be given most often for musculoskeletal problems, depth of advice did not appear to be related to the presenting problem. When physical activity advice was relevant and omitted, consultations prioritised another overriding presenting problem, or clinical management focussed on another intervention. Conclusion Physical activity advice, following national guidance, was potentially relevant to over half of GP consultations; GPs were able to deliver advice of varying depth in a third of these consultations. Future work should explore ways of delivering physical activity advice effectively, efficiently and equitably within the constraints of general practice. Keywords Physical activity; general practice; video recording.

MoCA use in general practice for the early detection of cognitive impairment.

GPs can detect cognitive impairment at a very early stage, allowing early support for people and their caregivers. The early onset of cognitive impairment is between 50 and 60 years. Currently, in France, the Mini Mental State Examination remains the most used screening test, though it has a lower sensitivity and specificity than the Montreal Cognitive Assessment (MoCA) for detecting mild cognitive impairment, taking an average of 15 minutes to complete. To investigate the feasibility of the MoCA during routine consultations in general practice for the early detection of cognitive impairment and to determine prevalence of cognitive impairment in a primary care setting. A quantitative, prospective feasibility study was carried out in real-life working condition during routine consultation. GPs performed MoCA on adults aged 50 years and older, without suspected or confirmed cognitive impairment. 61 GPs performed 221 MoCA with a mean duration of 8 minutes and detected mild neurocognitive impairment in 62% of patients. The MoCA is feasible and easy to perform during routine consultations in general practice by trained and experienced physicians.

Tumors of the central nervous system. Classification of the World Health Organization 2021. Towards a paradigm shift.

The study of central nervous system (CNS) tumors is a subject of great interest and such knowledge is of great importance in medical practice. The classifications of CNS neoplasms began in the mid-19th century, until the World Health Organization (WHO) published, in 1979, the first edition of a useful systematic review for the purpose of establishing a common language for all medical specialties. To date, 5 updated editions of neoplastic taxonomy have been published. The fifth edition, from 2021, consolidates the paradigm shift brought about by molecular advances, although the transition between morphological and molecular biological characterization is still in progress. In this article, the new modifications introduced in the different most frequent families of tumors in pediatrics are analyzed, emphasizing useful information for pediatricians in their daily practice and multidisciplinary consultations.

Evaluation of natural history communication and shared decision making for self-limiting conditions: Analysis of UK primary care consultations

ObjectiveTo analyse communication about the natural course of self-limiting illnesses, as part of shared decision-making (SDM), in general practice consultations. MethodsNatural history communication and SDM (using Observing Patient Involvement in Decision-Making (OPTION-12) and Assessing Communication about Evidence and Patient Preferences (ACEPP) items) were rated by two raters using transcripts from the UK ‘One in a Million’ database. ResultsOf 55 eligible consultations, a ‘wait and see’ option was mentioned in 27 consultations (49 %), using varying terminology, with a general recovery timeframe provided in 21. Mean OPTION-12 score (of 100) was 25.2 (SD=7.4), indicating a low level of SDM. Mean ACEPP score (out of 5) was 1.2 (SD=0.5), indicating minimal communication about the options’ benefits and harms. Recovery likelihood was quantified in only two consultations, while harms were quantified in none. ConclusionCommunication about the natural history of self-limiting illnesses was generally limited. The ‘wait and see’ approach, along with its benefits and harms, was typically not explicitly presented as an option for patients to consider. Practice ImplicationsImproving clinicians’ awareness of the importance of and skills for communicating the natural history of self-limiting illnesses, as part of SDM, may facilitate informed decision-making in managing these conditions.

GP remote consultations with marginalised patients and the importance of place during care: a qualitative study of the role of place in GP consultations.

Since COVID-19 there been an increase in the use of remote consultations in General Practice in the UK. This leads to the displacement of the consultation outside of the physical GP practice, and its 'emplacement' elsewhere, with underexplored consequences for inequities of healthcare in marginalised groups. This paper examines the place-making demands that remote consultations make on patients, and the ways that these affect their experiences of care, with a focus on the impact on patients from marginalised groups. Ethnography and interview study (n=15) undertaken at three sites in London: a foodbank, a community development organisation, and a drop-in advice centre for migrants. Additionally, GPs (n=5) working at practices in London Digital Health Hub staff (n=4) and staff at fieldwork sites (n=3) were interviewed. Ethnographic observation (n=84 hours) and semi-structured interviews (n=27). Interviews were conducted in-person and over the phone and data were analysed through reflexive thematic analysis. The core themes emerging from the data included challenges securing privacy during remote consultations, and the loss of formal healthcare spaces as important places of care. These findings were closely tied to resource access, leading to inequities in experiences of care. Remote GP consultations are not "place-less" encounters, and inequities in access to suitable spaces may lead to inequities in experiences of care. Attention should be given to ensuring that patients without appropriate spaces for remote consultations are offered in-person care, or consultation times made more specific to allow for organisation of private space.

Healthcare interpreting as relational practice: Understanding the interpreter’s role in facilitating rapport in health interactions

This article explores the extent to which healthcare interpreting can be considered “relational practice.” It describes an interactional sociolinguistic study conducted in Australia, based on video recordings of two naturally occurring interpreted general practice consultations. Participants were hearing Australian Sign Language (Auslan)/English interpreters, deaf patients, and hearing doctors. Analysis of these recordings was supplemented by reflective interviews with participants. The study examines the ways in which interpreters facilitate good working relationships between participants, and to explore the extent to which their decision-making is driven by relational considerations. The analyses presented in this article provide evidence that relational work is an important aspect of the healthcare interpreter’s role. Some of the ways in which it is achieved, however, may challenge our ideas about “appropriate” interpreter behaviour. Thus, the skilled and experienced interpreters in the study were seen to modify face threats, directly influence the flow of interaction, and actively facilitate social talk and humour, occasionally even engaging in it themselves. It is argued that interpreters’ decisions can only be understood within the discursive context in which they occur, and such behaviour can highlight interpreters’ attentiveness to the maintenance of good rapport.

Tailoring communication practices to support effective delivery of telehealth in general practice

BackgroundThe unprecedented increase in telehealth use due to COVID-19 has changed general practitioners’ (GP) and patients’ engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design.MethodsThis study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth.ResultsThree key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth.ConclusionsEffective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.

Asthma and COPD management of patients with intellectual disabilities in general practice

People with intellectual disabilities experience overall poorer health and healthcare access than the general population. It is largely unknown how this applies to asthma and chronic obstructive pulmonary disease (COPD) management by general practitioners (GPs). In a 10-year retrospective matched cohort study, n = 34,429, we examined year prevalence of asthma and COPD in adult patients with and without intellectual disabilities and potential differences in the delivery of asthma and COPD disease management activities in Dutch general practices (2010–2019). We collected information on patient characteristics, comorbidity, consultation patterns, use and outcomes of asthma/COPD control questionnaires, spirometry measurement, pulmonology referrals, and prescribed medication. Asthma patients with intellectual disabilities suffered more frequently from obesity (53.2% vs. 39.5% without intellectual disabilities), and both asthma and COPD patients with intellectual disabilities were more frequently current smokers (45.2% vs. 22.1% without intellectual disabilities, and 76.6% vs. 51.4% without intellectual disabilities, respectively). Also, a statistically significant larger number of asthma patients with intellectual disabilities were prescribed antibiotics (69.9% vs. 54.5%). COPD patients with intellectual disabilities, compared with matched controls without intellectual disabilities, received significantly more often either no COPD-related practice consultation at all (respectively 20.8% vs. 8.5%, p = 0.004) or a large number of practice consultations (>31 consultations, respectively 16.7% vs. 5.3%, p = 0.004). For asthma, there was no statistical difference between patients with or without intellectual disabilities regarding the number and type of consultations. The asthma year point prevalence in patients with intellectual disabilities was, from 2014 onward, significantly higher, and in 2019 was 8.7% vs. 6.0% for people without intellectual disabilities. For COPD, it was comparable in both groups. Both asthma and COPD patients with intellectual disabilities appeared considerably younger in age than patients without intellectual disabilities. Our findings warrant further research into the causes of the differences found for asthma and COPD and whether they also infer differences in the quality or the effectiveness of GP disease management, especially for young adults with intellectual disabilities.