Primary Care Department Research Articles

Lesbian, gay, bisexual, transgender and or queer patient experiences in Canadian primary care and emergency departments: a literature review

This literature review synthesises existing evidence and offers a thematic analysis of primary care and emergency department experiences of lesbian, gay, bisexual, transgender, queer and/or any other sexual or gender minority (LGBTQ+) individuals in Canada. Articles detailing first-person primary or emergency care experiences of LGBTQ + patients were included from EMBASE, MEDLINE, PsycINFO and CINHAL. Studies published before 2011, focused on the COVID-19 pandemic, unavailable in English, non-Canadian, specific to other healthcare settings, and/or only discussing healthcare provider experiences were excluded. Critical appraisal was performed following title/abstract screening and full-text review by three reviewers. Of sixteen articles, half were classified as general LGBTQ + experiences and half as trans-specific experiences. Three overarching themes were identified: discomfort/disclosure concerns, lack of positive space signalling, and lack of healthcare provider knowledge. Heteronormative assumptions were a key theme among general LGBTQ + experiences. Trans-specific themes included barriers to accessing care, the need for self-advocacy, care avoidance, and disrespectful communication. Only one study reported positive interactions. LGBTQ + patients continue to have negative experiences within Canadian primary and emergency care – at the provider level and due to system constraints. Increasing culturally competent care, healthcare provider knowledge, positive space signals, and decreasing barriers to care can improve LGBTQ + experiences.

A Closed Loop Two Cycle Audit Assessing the Prescription Practice of Topical Antibiotics for Acute Infective Conjunctivitis in a Primary Care Department

Background: The implementation of guideline recommendations for antibiotics prescription for the management of patients with Acute Infective Conjunctivitis (AIC) in primary care departments remains below par. Objectives: To assess the impact of clinical audit on adherence to evidence-based indications for prescription of antibiotic eye drops in patients diagnosed with AIC, in the setting of a primary care practice in western Greece. Methods: This was a closed loop two cycle audit to evaluate the current prescription practice of antibiotics for the managements of AIC. Following evidence-based indications for the prescription of antibiotics in AIC through literature search, and in combination with discussion and collaboration with the primary care doctors of our department, we formulated and implemented guidelines for the management of AIC. In the second cycle of the audit we assessed the management of patients with AIC after local implementation of the guidelines. Results: A total of 191 cases were audited in the first cycle before the introduction of the guidelines, from 15th June 2019 to 7th March 2020, and 140 cases after, from 10th March 2020 to 20th November 2020. The compliance with the guidelines regarding antibiotics prescription was significantly improved from 12.0% to 84.6% between the first and the second cycles of audit. Conclusion: In this study, clinical audit with locally introduction of guidelines significantly improved the prescription practice of topical antibiotics in patients with AIC in a primary care department.

A Closed Loop Two Cycle Audit Assessing the Prescription Practice of Topical Antibiotics for Acute Infective Conjunctivitis in a Primary Care Department

Background: The implementation of guideline recommendations for antibiotics prescription for the management of patients with Acute Infective Conjunctivitis (AIC) in primary care departments remains below par. Objectives: To assess the impact of clinical audit on adherence to evidence-based indications for prescription of antibiotic eye drops in patients diagnosed with AIC, in the setting of a primary care practice in western Greece. Methods: This was a closed loop two cycle audit to evaluate the current prescription practice of antibiotics for the managements of AIC. Following evidence-based indications for the prescription of antibiotics in AIC through literature search, and in combination with discussion and collaboration with the primary care doctors of our department, we formulated and implemented guidelines for the management of AIC. In the second cycle of the audit we assessed the management of patients with AIC after local implementation of the guidelines. Results: A total of 191 cases were audited in the first cycle before the introduction of the guidelines, from 15th June 2019 to 7th March 2020, and 140 cases after, from 10th March 2020 to 20th November 2020. The compliance with the guidelines regarding antibiotics prescription was significantly improved from 12.0% to 84.6% between the first and the second cycles of audit. Conclusion: In this study, clinical audit with locally introduction of guidelines sign

Associations Between Physical Activity Vital Sign in Patients and Health Care Utilization in a Health Care System, 2018-2020.

Physical inactivity is a risk factor for many chronic conditions. This retrospective cohort study examined associations between physical activity (PA) with health care utilization (HU). A PA vital sign was recorded in clinicsfrom January 2018 to December 2020. Patients were categorized as inactive, insufficiently active, or sufficiently active by US PA aerobic guidelines. Associations between PA vital sign and visits (inpatient admissions, emergency department, urgent care, and primary care) were estimated using population average regression by visit type. 23,721 patients had at least one PA vital sign recorded, with a mean age of 47.3 years and mean body mass index (BMI) of 28; 52% were female and 63% were White. Sufficiently active patients were younger, male, White, and had lower BMI than insufficiently active patients. Achieving 150 minutes per week of moderate to vigorous PA per 1000 patient years was associated with 34 fewer emergency department visits (P < .001), 19 fewer inpatient admissions (P < .001), and 38 fewer primary care visits (P < .001) compared with inactive patients. Stronger associations betweenlower PA and higher HU were present among those who were older or had a higher comorbidity. BMI, sex, ethnicity, and race did not modify the association between PA and HU. Meeting aerobic guidelines was associated with reduced HU for inpatient, primary care, and emergency department visits.

Effectiveness of an App for tobacco cessation in pregnant smokers (TOBBGEST): study protocol

BackgroundTobacco consumption during pregnancy is one of the most modifiable causes of morbidity and mortality for both pregnant smokers and their foetus. Even though pregnant smokers are conscious about the negative effects of tobacco consumption, they also had barriers for smoking cessation and most of them continue smoking, being a major public health problem. The aim of this study is to determine the effectiveness of an application (App) for mobile devices, designed with a gamification strategy, in order to help pregnant smokers to quit smoking during pregnancy and in the long term.MethodsThis study is a multicentre randomized community intervention trial. It will recruit pregnant smokers (200 participants/group), aged more than 18 years, with sporadically or daily smoking habit in the last 30 days and who follow-up their pregnancy in the Sexual and Reproductive Health Care Services of the Camp de Tarragona and Central Catalonia Primary Care Departments. All the participants will have the usual clinical practice intervention for smoking cessation, whereas the intervention group will also have access to the App. The outcome measure will be prolonged abstinence at 12 months after the intervention, as confirmed by expired-carbon monoxide and urinary cotinine tests. Results will be analysed based on intention to treat. Prolonged abstinence rates will be compared, and the determining factors will be evaluated using multivariate statistical analysis.DiscussionThe results of this study will offer evidence about the effectiveness of an intervention using a mobile App in smoking cessation for pregnant smokers, to decrease comorbidity associated with long-term smoking. If this technology is proven effective, it could be readily incorporated into primary care intervention for all pregnant smokers.Trial registrationClinicaltrials.gov ID NCT05222958. Trial registered 3 February 2022.

Prevalence of Type 2 Inflammatory Diseases in Pediatric Patients With Atopic Dermatitis: Real-world Evidence

To analyze the prevalence and incidence of type 2 inflammatory disease in pediatric patients with atopic dermatitis (AD) compared with a similar population of patients without AD, utilizing a large United States commercially insured database.The study included 244 776 pediatric AD patients matched 1:1 with non-AD patients from the IBM MarketScan Commercial Database from 2013 to 2017. This US database included representation from a variety of commercial insurance plan types throughout the country with 44% of patients from the South.This was a retrospective study conducted over a 12-month period that used a commercial database of select the patient populations. This database included diagnostic codes entered by clinicians for billing from a variety of providers, including primary care (pediatricians and family practitioners), subspecialists (allergy and dermatology), and emergency department or urgent care clinicians. Date of AD diagnosis was used for patients with AD and a random date for non-AD patients with required insurance 6 months prior and 12 months after date. AD patients were defined as <18 years with ICD 9 code (691.8) or ICD 10 code (L20×) and matched controls had no diagnosis of AD for the entirety of the study. Severity of disease was divided into 3 levels based on treatment. Level 1 included low potency topical steroids (class 5–7) or calcineurin inhibitors, level 2 included mid potency topical steroids or calcineurin inhibitors, and level 3 includes systemic steroids, phototherapy, immunosuppressants, or intravenous immunoglobulin. The prevalence of type 2 diseases including asthma, allergic conjunctivitis, chronic rhinosinusitis, nasal polyps, eosinophilic esophagitis, allergic rhinitis and urticaria was evaluated in 2 comparison groups: severity of disease (level 3 AD versus level 1 and 2) and presence or absence of AD. Furthermore, food allergy was omitted from the evaluation as it was felt it was poorly defined and without standardization. Logistic regression models were used for statistical comparison. Kaplan-Meier curves were used to show time to development of type 2 disease. Hazard ratios using a Cox proportional hazard model were reported for the risk of type 2 disease in AD versus non-AD patients.In this population database, patients who had AD at time of diagnosis (index) were more likely to develop type 2 inflammatory disease compared with patients without AD (odds ratio [OR] of 2.17, [2.15–2.20], P < .001). Asthma, eosinophilic esophagitis, urticaria and rhinitis were among conditions that were twice as likely diagnosed in AD patients. Chronic rhinosinusitis and nasal polyps had a slightly higher likelihood in AD patients (OR 1.10, [1.06–1.13]; P < .001). Patient with level 3 severity had 4 times the likelihood of asthma (OR 4.43, [4.32–4.54]; P < .001). Infants with AD demonstrate a higher risk for development of type 2 disease, with a hazard ratio of 1.47 (1.45–1.50) compared with non-AD patients. Based on the Kaplan-Meier curves, patients with AD had a 51.7% probability of developing type 2 inflammatory disease compared with non-AD patients who had a 38.9% probability.The relative prevalence of type 2 inflammatory disease was higher in pediatric patients with AD in a very large insurance-based database. In addition, the risk of developing type 2 inflammatory disease was higher in infants with AD over a 1-year period. Severity of AD was found to increase both the prevalence and risk.This study used a large national insurance database to examine the prevalence and incidence of type 2 inflammatory diseases (asthma, rhinitis, conjunctivitis, urticaria, eosinophilic esophagitis, and chronic rhinosinusitis or nasal polyps) in pediatric patients with AD. Authors analyzed an impressive cohort size and found a statistically significant higher incidence and prevalence of other allergic diseases within pediatric AD. There were a few limitations to further consider. First, authors were unable to quantify food allergy in this cohort due to concerns of nonstandardization of food allergy diagnostic criteria and associated codes. Though quantifying food allergy was a challenge, perhaps adding epinephrine prescription or food anaphylaxis may have been helpful. Secondly, the scoring of AD severity was based upon treatment regimens which, consequently, grouped all ages into 1 cohort. Patients on a high potency topical steroid were all considered level 2 (on a 1 to 3 scale), whereas in many cases an infant or toddler receiving this treatment would be considered severe. In addition, it was difficult to know if eczema was indeed the indication for the prescriptions. For example, in patients considered severe or level 3, treatments such as systemic steroids may have been given for asthma exacerbation and immunoglobulin replacement may have been used to treat an underlying immunodeficiency. Finally, extending the 1-year observation period would have provided a more complete evaluation of the incidence of other atopic conditions in infants and toddlers less than 2 years of age. This retrospective study added to work establishing an increased burden of type 2 inflammatory diseases found in patients with AD.URL: www.pediatrics.org/cgi/doi/10.1542/peds.10.1016/j.jaad.2021.10.038

Improving risk prediction model quality in the critically ill: data linkage study

Background A previous National Institute for Health and Care Research study [Harrison DA, Ferrando-Vivas P, Shahin J, Rowan KM. Ensuring comparisons of health-care providers are fair: development and validation of risk prediction models for critically ill patients. Health Serv Deliv Res 2015;3(41)] identified the need for more research to understand risk factors and consequences of critical care and subsequent outcomes. Objectives First, to improve risk models for adult general critical care by developing models for mortality at fixed time points and time-to-event outcomes, end-stage renal disease, type 2 diabetes, health-care utilisation and costs. Second, to improve risk models for cardiothoracic critical care by enhancing risk factor data and developing models for longer-term mortality. Third, to improve risk models for in-hospital cardiac arrest by enhancing risk factor data and developing models for longer-term mortality and critical care utilisation. Design Risk modelling study linking existing data. Setting NHS adult critical care units and acute hospitals in England. Participants Patients admitted to an adult critical care unit or experiencing an in-hospital cardiac arrest. Interventions None. Main outcome measures Mortality at hospital discharge, 30 days, 90 days and 1 year following critical care unit admission; mortality at 1 year following discharge from acute hospital; new diagnosis of end-stage renal disease or type 2 diabetes; hospital resource use and costs; return of spontaneous circulation sustained for &gt; 20 minutes; survival to hospital discharge and 1 year; and length of stay in critical care following in-hospital cardiac arrest. Data sources Case Mix Programme, National Cardiac Arrest Audit, UK Renal Registry, National Diabetes Audit, National Adult Cardiac Surgery Audit, Hospital Episode Statistics and Office for National Statistics. Results Data were linked for 965,576 critical care admissions between 1 April 2009 and 31 March 2016, and 83,939 in-hospital cardiac arrests between 1 April 2011 and 31 March 2016. For admissions to adult critical care units, models for 30-day mortality had similar predictors and performance to those for hospital mortality and did not reduce heterogeneity. Models for longer-term outcomes reflected increasing importance of chronic over acute predictors. New models for end-stage renal disease and diabetes will allow benchmarking of critical care units against these important outcomes and identification of patients requiring enhanced follow-up. The strongest predictors of health-care costs were prior hospitalisation, prior dependency and chronic conditions. Adding pre- and intra-operative risk factors to models for cardiothoracic critical care gave little improvement in performance. Adding comorbidities to models for in-hospital cardiac arrest provided modest improvements but were of greater importance for longer-term outcomes. Limitations Delays in obtaining linked data resulted in the data used being 5 years old at the point of publication: models will already require recalibration. Conclusions Data linkage provided enhancements to the risk models underpinning national clinical audits in the form of additional predictors and novel outcomes measures. The new models developed in this report may assist in providing objective estimates of potential outcomes to patients and their families. Future work (1) Develop and test care pathways for recovery following critical illness targeted at those with the greatest need; (2) explore other relevant data sources for longer-term outcomes; (3) widen data linkage for resource use and costs to primary care, outpatient and emergency department data. Study registration This study is registered as NCT02454257. Funding details This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 39. See the NIHR Journals Library website for further project information.

Appropriateness of antibiotic treatment of acute respiratory tract infections in Tunisian primary care and emergency departments: a multicenter cross-sectional study

BackgroundLittle is known about the pattern and appropriateness of antibiotic prescriptions in patients with acute respiratory tract infections (ARTIs).ObjectiveDescribe the antibiotics used to treat ARTIs in Tunisian primary care offices and emergency departments (EDs), and assess the appropriateness of their use.MethodsIt was a prospective multicenter cross-sectional observational clinical study conducted at 63 primary care offices and 6 EDS during a period of 8 months. Appropriateness of antibiotic prescription was evaluated by trained physicians using the medication appropriateness index (MAI). The MAI ratings generated a weighted score of 0 to 18 with higher scores indicating low appropriateness. The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards. The study was approved by the Ethics committee of Monastir Medical Faculty.ResultsFrom the 12,880 patients screened we included 9886 patients. The mean age was 47.4, and 55.4% were men. The most frequent diagnosis of ARTI was were acute bronchitis (45.3%), COPD exacerbation (16.3%), tonsillitis (14.6%), rhinopharyngitis (12.2%) and sinusitis (11.5%). The most prescribed classes of antibiotics were penicillins (58.3%), fluoroquinolones (17.6%), and macrolides (16.9%). Antibiotic therapy was inappropriate in 75.5% of patients of whom 65.2% had bronchitis. 65% of patients had one or more antibiotic prescribing inappropriateness criteria as assessed by the MAI. The most frequently rated criteria were with expensiveness (75.8%) and indication (40%). Amoxicillin-clavulanic acid and levofloxacin were the most inappropriately prescribed antibiotics. History of cardiac ischemia ([OR] 3.66; 95% [CI] 2.17–10.26; p < 0.001), asthma ([OR] 3.29, 95% [CI] 1.77–6.13; p < 0.001), diabetes ([OR] 2.09, 95% [CI] 1.54–2.97; p = 0.003), history of COPD ([OR] 1.75, 95% [CI] 1.43–2.15; p < 0.001) and age > 65 years (Odds Ratio [OR] 1.35, 95% confidence interval [CI] 1.16–1.58; p < 0.001) were associated with a higher likelihood of inappropriate prescribing.ConclusionOur findings indicate a high inappropriate use of antibiotics in ARTIs treated in in primary care and EDs. This was mostly related to antibiotic prescription in acute bronchitis and overuse of expensive broad spectrum antibiotics. Future interventions to improve antibiotic prescribing in primary care and EDs is needed.Trial registrationthe trial is registered at Clinicaltrials.gov registry (NCT04482231).

Casual Behaviors in Telemedicine

Background: Telemedicine is emerging as a new way for patients to access medical care. When patients are allowed to conduct video or audio visits from home, it can empower them to be more casual in their interactions with their providers. Objective: The purpose of this study is to identify provider attitudes regarding various telemedicine situations. From this study, a standard of care for telemedicine scenarios may start to be determined which can empower physicians to deal with various scenarios they may encounter. Design: A mass survey regarding questions related to certain casual patient behaviors and provider comfort and acceptance of these behaviors was sent out to providers at the Primary care, Family medicine, and Internal medicine departments at Loyola University Medical University. Results: 42 providers responded to the survey who was predominantly white female physicians at the medical center. In regards to patient behaviors, there was a significant difference between the levels of casualness providers ranked themselves versus their comfort level with various patient behaviors. More than half of the respondents had a difficult telehealth encounter but only half of the providers actually attempted to rectify the patient behavior. Conclusion: Problematic patient behavior during telehealth encounters poses a new challenge to many providers. A better understanding of which patient behaviors and activities cause providers distress is important to assess. However, the next step involves creating set guidelines and protocols to empower providers to speak up during difficult telehealth visits.

Rehabilitation After Pediatric and Adolescent Knee Injuries.

According to epidemiology studies, the majority of youth sports injuries presenting to primary care, athletic trainers, and emergency departments impact the musculoskeletal system. Both acute and overuse knee injuries can contribute to sports attrition before high school. Effective rehabilitation of knee injuries ensures a timely return to sports participation and minimizes the negative physical, psychological, and social consequences of becoming injured. The following article provides rehabilitation and returns to play strategies for postsurgical and nonsurgical injuries of the young athlete's knee.

Validation study of machine-learning chest radiograph software in primary and emergency medicine

To evaluate the performance of a machine learning based algorithm tool for chest radiographs (CXRs), applied to a consecutive cohort of historical clinical cases, in comparison to expert chest radiologists. The study comprised 1,960 consecutive CXR from primary care referrals and the emergency department (992 and 968 cases respectively), obtained in 2015 at a UK hospital. Two chest radiologists, each with >20 years of experience independently read all studies in consensus to serve as a reference standard. A chest artificial intelligence (AI) algorithm, Lunit INSIGHT CXR, was run on the CXRs, and results were correlated with those by the expert readers. The area under the receiver operating characteristic curve (AUROC) was calculated for the normal and 10 common findings: atelectasis, fibrosis, calcification, consolidation, lung nodules, cardiomegaly, mediastinal widening, pleural effusion, pneumothorax, and pneumoperitoneum. The ground truth annotation identified 398 primary care and 578 emergency department datasets containing pathologies. The AI algorithm showed AUROC of 0.881-0.999 in the emergency department dataset and 0.881-0.998 in the primary care dataset. The AUROC for each of the findings between the primary care and emergency department datasets did not differ, except for pleural effusion (0.954 versus 0.988, p<0.001). The AI algorithm can accurately and consistently differentiate normal from major thoracic abnormalities in both acute and non-acute settings, and can serve as a triage tool.

Health Care Use Prior to Diabetes Diagnosis in Children Before and During COVID.

During COVID-19, healthcare systems reorganized with less ambulatory care and a shift to virtual care (1). There was an increase in diabetic ketoacidosis (DKA), a preventable, life-threatening condition, at diabetes onset in children during COVID-19 (2). DKA at diabetes onset has been attributed to delays in seeking care, missed diagnosis or delays in referral following a primary healthcare contact (3). Reasons for the recent increase in DKA may relate to hesitancy to seek care, providers failing to recognize diabetes symptoms due to cognitive bias focusing on COVID-19, or limitations of virtual care. To explore these potential mechanisms, we compared in-person and virtual primary care and emergency department (ED) visits in children four weeks prior to diagnosis, before and during COVID-19. If increased DKA rates during COVID-19 were due to more missed diagnoses, possibly related to virtual visits, children with DKA would be more likely to have visits during vs. pre-COVID-19. If families were hesitant to seek or unable to access care during COVID-19, then among those with no visits, there would be a higher proportion with DKA.

Time intervals in the care pathway to cancer diagnosis during the COVID-19 pandemic: A large retrospective study from a high-volume center.

Despite extensive research on cancer care during the COVID‐19 pandemic, evidence on the impact on prediagnostic time intervals is lacking. To better understand how COVID‐19 changed the pathway to diagnosis of cancer, we examined the length of intervals from symptom onset to diagnosis for 13 common cancer types with known clinical stage over 1‐year nonpandemic period (March 2019 to March 2020; N = 844) and three biannual COVID periods (March 2020 to September 2021; N = 1172). We analyzed the patient interval (from first symptoms to presentation to a physician), the primary care/emergency department interval (from presentation with relevant symptoms to a primary care or emergency department physician to referral to a hospital‐based diagnosis center) and the hospital interval (from referral to diagnosis). Compared to nonpandemic data, there were significant changes across COVID periods. The pandemic mostly impacted patient intervals for cancers diagnosed over the first 6 months after onset in March 2020. Overall median patient intervals were longest in the early COVID period (39 [IQR 22‐64] days) and shortest in the nonpandemic period (20 [IQR 13‐30] days; Kruskal‐Wallis test [χ 2], P < .0001). Differences in clinical stage between periods were relevant, with cancers from the mid‐period (September 2020 to March 2021) showing the most advanced stage. A shift to later stage was plausibly a result of delayed intervals in the early COVID period. Since intervals are eventually relevant to prognosis, our results provide a baseline against which the impact of improvement strategies to minimize the negative outcomes of COVID‐19‐associated cancer delays can be assessed and implemented.

Item Has Been Withdrawn

ObjectivesApproximately 70% of people in British Columbia’s provincial prisons have mental health and/or substance use disorders. Many serve short sentences, and cycle frequently between corrections and community. This study examines mental health (MH) services access and reincarceration among people with a mental illness released from British Columbia’s provincial prisons.&#x0D; ApproachA 20% random sample of the general population of British Columbia (BC) (N=1,089,682) contained within BC’s Provincial Overdose Cohort was used. People who had a record of release from a provincial correctional centre between January 1 2015- December 31st 2018, and a mental illness diagnosis in the year prior to release were eligible for inclusion (N=3,907). MH services access was determined using primary care, hospitalization and emergency department records, and reincarceration and additional covariates were retrieved from linked provincial health and corrections records. Hazards of MH services access and reincarceration were calculated using state arrival extended cox proportional hazards models.&#x0D; ResultsOf the 3907 releases, 45.9% (N=1795) had MH services access following release, while 40.5% (N=1584) ended in reincarceration without MH services access. The remaining releases were censored prior to observing either outcome. Of those with MH services access, 59.4% (N=1067) ended in subsequent reincarceration. The hazard of reincarceration was elevated for people with concurrent substance use disorder, among both people who did (HR: 1.33 (95%CI: 1.13-1.57) and did not (HR: 1.55(95%CI: 1.22-1.81)) access MH services prior to reincarceration. MH services access had a protective effect on reincarceration (HR: 0.64 (95%CI:0.42-0.99)). Timeliness of MH services access was protective, such that each additional month that passed between release and subsequent MH services access was associated with a 5% increase in the hazard of reincarceration (HR: 1.05(95%CI: 1.02-1.08)).&#x0D; ConclusionMental health services access upon release from prison reduces risk of reincarceration. The timeliness of services access plays a critical role in reducing return to reincarceration. Efforts targeted at increasing accessibility of timely mental health services for this population can support increase individual well-being an reduce reincarceration.

SP3.1.10 The use of predictive severity scoring for lower gastrointestinal bleeding in a tertiary colorectal unit

Abstract Introduction Lower GI bleeding (LGIB) has an estimated 1-year prevalence of 10% in the UK, accounting for 3% of emergency surgical referrals. The British Society of Gastroenterology (BSG) recommend risk scoring for LGIB to categorise severity and plan management. Experience in a tertiary colorectal centre suggests this potentially overestimates the severity of bleeding and the requirement for inpatient admission. Method Data was retrospectively collected for all patients referred from primary care or emergency departments with LGIB from 01/05/20–01/04/21. Demographics and an Oakland score (OS), recommended in BSG guidelines, were collected. OS &amp;gt;8 suggests admission. Outcomes following referral, including admission, discharge, blood transfusion and radiological/surgical intervention, were assessed. Results 294 patients were assessed. 176 patients (59.9%) were admitted for further management. The median OS for admitted patients was 12 (IQR 9–17). 30 patients (10.2%) required blood transfusion, 3 required radiological/surgical intervention (1%). 118 (40.1%) patients were discharged. The median OS was 10 (IQR 8–12). 80 patients discharged had a score &amp;gt;8, recommending admission; 4 patients required readmission (5.0%), however, none required intervention. 38 patients were discharged with a score ≤8; again, 4 patients (10.5%) required readmission for LGIB, with none requiring intervention. Fisher's exact test showed no statistical significance between OS and readmission (p=0.22). Conclusion Risk assessment scoring recommended admission for a large cohort of patients safely discharged after initial assessment in our centre. A small number required readmission, however, none suffered significant adverse outcomes. Further investigation should assess whether such scoring systems are too cautious for use in specialist colorectal centres.

Association between access to primary care and unplanned emergency department return visits among patients 75 years and older.

To identify factors associated with unplanned return visits to the emergency department (ED) among the population aged 75 years and older. Moreover, it aims to determine the association between patients' access to primary care and unplanned return visits. Data were collected from structured interviews, administrative databases, and medical charts at the index visits, and follow-up telephone calls were made at 3 months. Emergency departments of the 3 tertiary care hospitals in Montréal, Que. Community-dwelling patients aged 75 years and older. Zero-inflated negative binomial regression analysis was conducted of unplanned return visits within 3 months. Rate ratios (RRs) and odds ratios (ORs) with 95% CIs are presented. During the study period, 4577 patients were identified, 2303 were recruited, and 1998 were retained for the analysis. Among the analysis sample, 33% were 85 and older, 34% lived alone, and 91% had a family physician. Before their ED visits, 16% of patients attempted to contact their family physicians. More than half of the patients reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems. Within 3 months, 562 patients (28%) had made 894 return visits. Factors associated with a lower return visit rate included age 85 years and older (RR=0.80; 95% CI 0.67 to 0.96), less severe triage score (RR=0.83; 95% CI 0.74 to 0.92), and hospitalization at the index visit (RR=0.76; 95% CI 0.64 to 0.90). Factors that resulted in a higher return visit rate were difficulty booking appointments for new problems with their family physicians (RR=1.19; 95% CI 1.01 to 1.41), having had ED visits within the previous 6 months (RR=1.47; 95% CI 1.28 to 1.68), and higher Charlson comorbidity index scores (RR=1.06; 95% CI 1.01 to 1.11). Having had ED visits within the previous 6 months (OR=2.11; 95% CI 1.27 to 3.49), having a higher Charlson comorbidity index score (OR=1.41; 95% CI 1.19 to 1.68), and having received community care services (OR=3.00; 95% CI 0.95 to 9.53) also increased the odds of return visits. Although most people 75 years and older have a family physician, problems still exist in terms of timely access. Unplanned return visits to the ED are associated with having more comorbidities, having had previous ED visits, having already received community services, and having difficulty booking appointments with family physicians for new problems.

Empathy in patient-clinician interactions when using telecommunication: A rapid review of the evidence.

ObjectivesThe COVID-19 pandemic accelerated the replacement of many face-to-face healthcare consultations with telephone consultations. Little is known about the extent to which empathy can be expressed in telephone consultations. Our objective is to review evidence related to empathy in telephone consultations including clinical outcomes, and patient/practitioner experiences.MethodsSearches of Medline/Ovid and PsycINFO/Ovid were undertaken. Titles and abstract screening, data extraction, and risk of bias were undertaken by two reviewers. Discrepancies were resolved in discussion with additional reviewers. Included studies were specific to tele-communications with empirical data on empathy related to patient outcomes/views, published (in English), 2010–2021. Studies that did not mention empathy explicitly were excluded.ResultsOur search yielded 740 individual records and 8 studies (527 patients, 20 practitioners) met inclusion criteria: Some barriers to expression of empathy were noted, but no major obstacles were reported. However, data was sparse and most studies had a high risk of bias.ConclusionEmpathy in telephone consultations is possible, (though the loss of non-verbal cues and touch can present barriers) however the research does not yet identify how.InnovationIt is possible to establish and display empathy in telephone consultations, but future research needs to identify how this can be optimized.FundingThis work was supported by a 10.13039/501100000272National Institute for Health Research (NIHR) 10.13039/501100013374School for Primary Care Research grant (project number 389). The 10.13039/501100000739University of Southampton's Primary Care Department is a member of the 10.13039/501100013374NIHR School for Primary Care Research and supported by NIHR Research funds. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.Protocol registration.PROSPERO (CRD42021238087).

Off-label use of fixed-dose combination of tramadol and dexketoprofen in primary health care. Evidence-based or cause for concern?

Introduction: The use of the fixed-dose combination of tramadol/dexketoprofen in Spain and in other countries has increased considerably. The authorized therapeutic indication for this medicinal product is the short-term symptomatic treatment of moderate to severe acute pain in adult patients. The objective of this study was to describe the pattern of use of tramadol/dexketoprofen in the field of primary health care. Method: A cross-sectional, descriptive and multicenter study was carried out. The study population included all patients from a Primary Care Department (53 Primary Care teams) with an active prescription of tramadol/dexketoprofen on March 28, 2018. The target population was those patients who were prescribed tramadol/dexketoprofen. dexketoprofen for &gt;20 days. Results: A total of 176 patients had an active prescription for tramadol/dexketoprofen. All patients (100%) had a duration of treatment greater than 5 days and 72.7% (N=128) greater than 20 days. The mean duration of treatment was 14±160.9 days in patients who had less than 20 days of treatment and 224±160.8 days in patients who had more than 20 days of treatment. 35.1% of the patients were treated with &gt;2 pain medications and concomitantly with tramadol/dexketoprofen. The general practitioner initiated 65.6% of the prescriptions. Conclusions: The fixed-dose combination of tramadol/dexketoprofen was frequently used off-label, according to the product characteristics and the available scientific evidence. This study warns about the potential risks associated with the use of this drug in clinical practice, such as lack of effectiveness and/or the appearance of adverse effects.

Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings.

There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges. Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice. The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support. Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas

ObjectiveThe objective of this study was to estimate the association between early use of physical therapy (PT) or chiropractic care and incident opioid use and long-term opioid use in individuals with a low back pain (LBP) diagnosis. MethodsA retrospective cohort study was conducted using data from Arkansas All Payers’ Claims Database. Adults with incident LBP diagnosed in primary care or emergency departments between July 1, 2013, and June 30, 2017, were identified. Participants were required to be opioid naïve in the 6-month baseline period and without cancer, cauda equina syndrome, osteomyelitis, lumbar fracture, and paraplegia/quadriplegia in the entire study period. PT and chiropractic treatment were documented over the ensuing 30 days starting on the date of LBP. Any opioid use and long-term opioid use (LTOU) in 1-year follow-up were assessed. Multivariable logistic regressions controlling for covariates were estimated. ResultsA total of 40 929 individuals were included in the final sample, with an average age of 41 years and 65% being women. Only 5% and 6% received PT and chiropractic service, respectively, within the first 30 days. Sixty-four percent had incident opioid use, and 4% had LTOU in the follow-up period. PT was not associated with incident opioid use (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.98-1.18) or LTOU (OR, 1.19; 95% CI, 0.97-1.45). Chiropractic care decreased the odds of opioid use (OR, 0.88; 95% CI, 0.80-0.97) and LTOU (OR, 0.56; 95% CI, 0.40-0.77). ConclusionIn this study we found that receipt of chiropractic care, though not PT, may have disrupted the need for opioids and, in particular, LTOU in newly diagnosed LBP.