Primary Care Referrals Research Articles

Virtual clinic for hearing loss and non-pulsatile tinnitus: initial experience of 210 cases.

Patients with hearing loss and tinnitus face lengthy waits to be seen in the ENT clinic. SHOEBOX Audiometry is an iPad-based, audiometric screening tool. A virtual hearing loss and non-pulsatile tinnitus clinic involving an ENT specialist virtually assessing cases based on the SHOEBOX audiogram, a patient symptom questionnaire and the primary care referral letter were implemented. This service evaluation explored the outcomes of the virtual clinic in reducing the need for a face-to-face ENT appointment. This was a retrospective service evaluation of the first six months of the virtual hearing loss and non-pulsatile tinnitus clinic. A total of 210 patients were included: 34.8 per cent (73) were discharged without requiring audiologist assessment or an ENT appointment, 51.9 per cent (109) required formal audiological assessment, 36.7 per cent (77) required imaging and only 13.8 per cent (29) required a face-to-face ENT appointment. A virtual hearing loss and non-pulsatile tinnitus clinic minimised the number of patients requiring a traditional face-to-face clinic appointment within ENT.

Changing primary care requesting practices for MRI knee: A quality improvement project

ObjectivesThe objectives of this work were first to examine referral practices from primary care for MRI knee in patients ≥45 years old and then to develop a new referral pathway to reduce the number of inappropriate MRI knee referrals. Following this, the aim was to re-assess the effect of the intervention and identify further areas for improvement. MethodsA baseline retrospective analysis of knee MRIs requested from primary care in symptomatic patients ≥45years over a two-month period was undertaken. A new referral pathway was implemented in consensus with orthopaedic specialists and the clinical commissioning group (CCG), via the CCG resource webpage and local education. Following implementation, a repeat data analysis was undertaken. ResultsThe number of MRI knees acquired from primary care referrals reduced by 42% after the new pathway was implemented. 67% (46/69) were compliant with the new guidelines. The number of patients having an MRI knee without a prior plain radiograph was 14/69 (20%) compared to 55/118 (47%) prior the pathway changes. ConclusionThe new referral pathway reduced the number of knee MRI acquisitions in primary care patients ≥45 years by 42%. Changing the pathway has decreased the number of patients undergoing MRI knee without a prior radiograph from 47% to 20%. These outcomes bring our standards towards the evidence-based recommendations of the Royal College of Radiology and have reduced our outpatient waiting list for MRI knee.Implications for practice: Implementing a new referral pathway with the local CCG can successfully reduce the number of inappropriate MRI knee acquisitions from primary care referrals in older symptomatic patients.

Development and initial evaluation of a behavioural intervention to support weight management for people with serious mental illness: an uncontrolled feasibility and acceptability study

BackgroundThe rates of obesity and associated health problems are higher in people with serious mental illness (SMI), such as schizophrenia and bipolar disorder, than the general population. A primary care referral to a behavioural weight management programme can be an effective intervention, but people with SMI have reported barriers to engaging with them and bespoke options are rarely provided in routine practice. It is possible that adjunct support addressing these specific barriers could help. Here we report the development, feasibility and acceptability of an intervention to improve uptake and engagement with a mainstream weight management programme for people with SMI.MethodsWe worked with people with a lived-experience of SMI and used the person-based approach to develop the ‘Weight cHange for people with sErious mEntal iLlness’ (WHEEL) intervention. It comprised a referral to a mainstream weight management programme (WW®) to be attended once a week, in-person or online, for 12-weeks. The adjunct support comprised a one-off, online consultation called Meet Your Mentor and weekly, telephone or email Mentor Check Ins for 12-weeks. We assessed the feasibility of WHEEL through the number of programme and adjunct support sessions that the participants attended. We analysed the acceptability of WHEEL using a thematic analysis of qualitative interviews conducted at baseline and at 12-week follow-up. Our exploratory outcome of clinical effectiveness was self-reported weight at baseline and at end-of-programme.ResultsTwenty participants were assessed for eligibility and 17 enrolled. All 17 participants attended Meet Your Mentor and one was lost to follow-up (94% retention). Nine out of 16 attended ≥50% of the weekly programme sessions and 12/16 attended ≥50% of the weekly check-ins. Participants reported in the interviews that the adjunct support helped to establish and maintain a therapeutic alliance. While some participants valued the in-person sessions, others reported that they preferred the online sessions because it removed a fear of social situations, which was a barrier for some participants. The mean change in self-reported weight was − 4·1 kg (SD: 3·2) at 12-weeks.ConclusionsA mainstream weight management programme augmented with brief and targeted education and low-intensity check-ins generated sufficient engagement and acceptability to warrant a future trial.

Impact of the COVID-19 Outbreak-Delayed Referral of Colorectal and Lung Cancer in Primary Care: A National Retrospective Cohort Study.

The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

P880 High incidence of inflammatory bowel disease in Northern Australia: a prospective community population-based Australian incidence study in the Mackay-Isaac-Whitsunday region

Abstract Background The Mackay-Isaac-Whitsunday region encompasses 173,892 people within a 400 km (250mile) radius in Queensland, Australia. We aimed to determine the incidence of Inflammatory Bowel Disease (IBD) in this region in northern Australia (-21.14°S) and to allow a comparison with southern Australian and New Zealand data (Geelong, Australia -38.14°S; Tasmania -41.43°S and -42.88°S [Launceston and Hobart] and Canterbury, New Zealand -43.46 °S). Methods A prospective observational community population-based IBD study was conducted between 1 June 2017 and 31 May 2018. Primary outcome measures include the crude annual incidence rate of IBD, Crohn's disease (CD), Ulcerative colitis (UC) and infammatory bowel disease unspecified (IBDU), while secondary outcomes includes disease phenotype and behaviour. All new cases were identified through primary health care referrals and public and private hospital referrals into the clinic. All new cases of IBD were prospectively defined using rigorously recognised and accepted criteria and categorised using the Montreal Classification. Results Fifty-six new cases of IBD were identified. Twenty-three were CD, 30 were UC and 3 were IBDU. The crude annual incidence rate per 100 000 for IBD, CD, UC and IBDU was 32.2 (95% confidence interval (CI): 24.78–41.84), 13.23 (95% CI: 8.79– 19.90), 17.25 (95% CI: 12.06–24.67) and 1.73 (95% CI: 0.56–5.35). When directly age-standardised to the World Health Organisation Standard Population Distribution, the overall CD, UC and IBDU incidence were 13.19, 17.34 and 1.85 per 100 000, with an overall age-standardised IBD incidence of 32.38. Conclusion This is the first study to define the incidence of IBD in a Northern Australian cohort and to allow a comparison between North and Southern Australia. The IBD crude is the highest reported in Australia. Like others, we found a high and low incidence of upper gastrointestinal Crohn's disease and complicated disease at diagnosis respectively, likely reflective of the increased availability and early uptake of endoscopic procedures.

P126 Ask twice: The importance of repeated faecal calprotectin testing prior diagnostic colonoscopy in an adult inception cohort

Abstract Background Elevated Faecal Calprotectin (FCP) is established as a valuable tool in differentiating Inflammatory Bowel Disease (IBD) from Irritable bowel syndrome (IBS) and monitoring IBD activity. Initial implementation studies in the UK demonstrated benefit from repeat testing to exclude false positives. This is not currently mandated by IBD consensus guidelines. Growing waiting times are increasing pressure to include a single result in straight to test pathways. No one level for significant elevation is defined with levels between 100-250ug/g used. We present our experience of the real-world utility of FCP used in a primary care referral pathway. Methods From Jan 2021-Nov 2022, new referrals were streamed into a rapid access ‘Inception IBD’ clinic on the basis of symptoms and raised FCP. A repeat FCP (kit sent in advance) was brought to the first appointment, with same day processing using the Buhlmann fCAL Turbo Test. Results and accompanying diagnosis and outcome data was collected prospectively. There was no standardised testing interval but median time from referral to review was 34 days. Results A single FCP was available for 425 patients with a final diagnosis. Two pre-treatment FCPs were available in 185. Median initial FCP was 949ug/g in those subsequently diagnosed with IBD (Ulcerative colitis 1162ug/g, Crohn’s 893ug/g) vs 353ug/g in those without IBD. This difference heightened on retesting, with median FCP in IBD 749ug/g vs 34ug/g in non-IBD (Fig 1). FCP fell between 1st and 2nd measurement in 88.6% of patients who had IBD excluded. In IBD, baseline FCP showed strong correlation with established disease activity markers (Fig 2). Baseline FCP levels were significantly higher in IBD patients who went on to require biologic treatment (Mann-Whitney U 2763, p&amp;lt;0.001). A variety of FCP cut-off values were assessed (Fig 4). A two sample &amp;gt;200ug/g cut off performed best as assessed by Area Under the Curve (AUC). However, sensitivity fell to 81.5% at this level. Of 15 IBD patients who didn’t have two FCPs &amp;gt;200ug/g, 7 had an increase between the 1st and 2nd FCP (median 147 vs 487ug/g). The remaining 8 comprised 4 ileal Crohn’s, 3 mild proctitis and 1 stricturing colonic Crohn’s in whom FCP failed to correlate with disease activity. Overall, 83% (48/58) of patients with increasing 1st to 2nd FCP were diagnosed with IBD. Conclusion Our data supports repeat testing of FCP to avoid unnecessary investigations adding to post COVID endoscopy backlogs. A cut off of two values &amp;gt;200ug/g had the best overall performance but can miss a small number of IBD cases, particularly those with isolated ileal disease or a more indolent disease course. This cut off should not be used in those with a marked increase between 1st and 2nd result, where IBD is likely.

The increasing burden of the 2-week wait colorectal cancer pathway in a single centre: the impact of faecal immunochemical tests.

Two-week wait (TWW) volume and colorectal cancer (CRC) detection pose an increasing challenge for NHS cancer services. Primary aims were to assess the introduction of faecal immunochemical tests (FIT) into clinical practice at our centre, the impact on TWW referral volume and CRC diagnoses, and to provide an update to previously published work. A secondary aim was to correlate FIT value and investigation. TWW CRC data following incorporation of FIT into clinical practice were analysed (1 June 2019-31 July 2021). Parameters assessed were monthly referral volume, CRC detection, primary care FIT volume and secondary care investigations. Referrals and CRC detection rates were compared with previously published data (2009-2019). Data relating to primary care FIT were collated from Berkshire and Surrey Pathology Services. TWW referrals increased 360% (2009-2020). CRC incidence decreased from 8.87% to 3.24%. Following incorporation into clinical practice, primary care FIT requests have increased to >450/month and accompanied 1,722/4,796 referrals. CRC incidence is static (3-4%). Patients with FIT <10µg Hb/g faeces undergo radiological imaging more commonly, whereas FIT-positive patients are more likely to undergo endoscopy, although the difference is not statistically significant. No significant change in CRC diagnosis was observed, despite increasing TWW referrals. Increasing utilisation of FIT in both primary and secondary care has helped maintain CRC detection while avoiding diagnostic delay. This study supports growing evidence highlighting the value of FIT in triage, referral and TWW investigation. FIT appears increasingly important for allocating secondary care resources (endoscopy), while guiding primary care referral. Additional low-cost strategies to determine prioritisation or reassurance (e.g. repeat FIT) require further evaluation.

A clinician-to-clinician universal electronic consultation programme at the cardiology department of a Galician healthcare area improves healthcare accessibility and outcomes in elderly patients.

We aimed to assess longer-term results (accessibility, hospital admissions, and mortality) in elderly patients referred to a cardiology department (CD) from primary care using e-consultation in outpatient care. We included 9963 patients >80 years from 1 January 2010 to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult programme (2013-2019) for all primary care referrals to cardiologists that preceded a patient's in-person consultation when considered. We used an interrupted time series (ITS) regression approach to investigate the impact of e-consultation on (i) cardiovascular hospital admissions and mortality. We also analysed (ii) the total number and referral rate (population-adjusted referred rate) in both periods, and (iii) the accessibility was measured as the number of consultations and variation according to the distance from the municipality and reference hospital. During e-consultation, the demand for care increased (12.8 ± 4.3% vs. 25.5 ± 11.1% per 1000 inhabitants, P < 0.001) and referrals from different areas were equalized. After the implementation of e-consultation, we observed that the increase in hospital admissions and mortality were stabilized [incidence rate ratio (iRR): 1.351 (95% CI, 0.787, 2.317), P = 0.874] and [iRR: 1.925 (95% CI: 0.889, 4.168), P = 0.096], respectively. The geographic variabilities in hospital admissions and mortality seen during the in-person consultation were stabilized after e-consultation implementation. Implementation of a clinician-to-clinician e-consultation programme in outpatient care was associated with improved accessibility to cardiology healthcare in elderly patients. After e-consultations were implemented, hospital admissions and mortality were stabilized.

Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis.

Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications. Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management. Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment. "Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.

Agreement and consistency in the triaging of musculoskeletal primary care referrals by vetting clinicians using a knowledge-based triage tool.

Primary care referrals received by secondary care services are vetted or triaged to pathways best suited for patients' needs. If knowledge-based triaging is used by vetting clinicians, accuracy is required to avoid incorrect decisions being made. With limited evidence to support best practice, we aimed to evaluate consistency across vetting clinicians' decisions and their agreement with a criterion decision. Twenty-nine trained vetting clinicians (18 female) representative of pay grades independently triaged five musculoskeletal physiotherapy referral cases into one of 10 decisions using an internally developed triage tool. Agreement across clinicians' decisions between and within cases was assessed using Fleiss's kappa overall and within pay grade. Proportions of triage decisions consistent with criterion decisions were assessed using Cochran's Q test. Clinician agreement was fair for all cases (κ = 0.385) irrespective of pay grade but varied within clinical cases (κ = -0.014-0.786). Proportions of correct triage decisions were significantly different across cases [Q(4) = 33.80, P < 0.001] ranging from 17% to 83%. Agreement and consistency in decisions were variable using the tool. Ensuring referrer information is accurate is vital, as is developing, automating and auditing standards for certain referrals with clear pathways. But we argue that variable vetting outcomes might represent healthy pathway abundance and should not simply be automated in response to perceived inefficiencies.

How a commissioning support unit increased primary care referrals from the Black Country Integrated Care System to the NHS Diabetes Prevention Programme

How a commissioning support unit increased primary care referrals from the Black Country Integrated Care System to the NHS Diabetes Prevention Programme

Lung cancer recovery focus post pandemic: an income-deprived area paradigm

'Stage shift' has been proposed as a marker of impact of Coronavirus 2019 (COVID-19) in lung cancer services; however, there are no data available specifically from income-deprived areas. Thus, this study evaluated the impact of the COVID-19 pandemic on lung cancer care in our area (Corby; among the most income deprived in England) and identified focus recovery areas. The study was a retrospective observational study of 668 consecutive patients with lung cancer at a district general hospital, pre-, during and after the COVID peak. Outcomes were the overall number of cases, presenting staging and treatment pathway. Overall, 32 fewer patients were diagnosed during the pandemic, with more inpatient diagnoses (p=0.01) and fewer primary care referrals (p<0.0001). There were no differences observed in treatment intent or 'stage shift'. Our results suggest that COVID-19 negatively affected the whole lung cancer pathway in our area. However, 'stage shift' might not be ideal to assess the impact of COVID-19 in income-deprived areas. Further studies will help the strategic rollout of a screening programme to identify patients with lung cancer earlier on in such areas.

Primary CNS Lymphoma in an Immunocompetent Patient: An Unusual Case Illustrating the Usual Problems Facing Brain Tumour Management in a Lower-Middle-Income Country

Primary central nervous system lymphoma (PCNSL) is a rare extra-nodal non-Hodgkin lymphoma (NHL). It primarily affects the immunocompromised but is rarely seen in immunocompetent individuals. The pitfalls in the healthcare system of lower-middle-income countries produce many obstacles, impeding timely diagnosis, timely treatment, and optimal quality of care. A 57-year-old immunocompetent, diabetic female presented with progressive generalised fatiguability, forgetfulness, and subtle behavioural changes for the last one and a half years. MRI revealed an area of gyri from dense post-contrast enhancement in the right posterior parietal region. Her symptoms kept aggravating with periods of partial remission as steroids were being administered. Reasons for delays in diagnosis and hence timely treatment include lack of primary care referral, conflicting neurosurgical opinion, and absence of multidisciplinary team management. A right posterior parietal parasagittal craniotomy was performed to excise the lesion. The patient was subsequently referred for adjuvant therapy. We use our patient's clinical journey to exemplify the structural barriers to providing optimal and timely care for brain tumour patients in a developing country. Primary CNS Lymphomas in immunocompetent patients are rare. Poor infrastructure and referral pathways contribute to delayed diagnosis. Lack of multi-disciplinary care owing to organisational issues is a major problem faced by brain tumour patients in a lower-middle-income country like ours. Brain tumour management requires a specialist multidisciplinary team approach to ensure timely diagnosis and optimal treatment

Idiopathic Scoliosis Trends One Year After COVID-19: A Retrospective Study.

Introduction The reorganization of healthcare services during the COVID-19 pandemic was associated with compromised management of conditions not related to the pandemic. Methods Aretrospective descriptive case series study was carried out that included patients followed up at the Spine Deformities (SD) consultation at Centro Hospitalar e Universitário Lisboa Centralfrom January 2019 through December 2021regarding diagnosis, treatment, referral, and the number of consultations performed. Results Referrals significantly dropped in 2020 (p<0.001).The average number of consultations per patient was found to not vary significantly in 2020despite the reorganization of our healthcare unit due to the pandemic.22% of the consultations were performed online. Idiopathic scoliosis (IS) was the primary diagnosis in 50% of the patients observed for the first time during the three-year time period. An increase of 18% was found in the number of IS patients that required bracing in 2021. However, late referrals, defined as the patient meeting surgical criteria at the time of initial presentation, did not increase. Conclusion Despite the significant decrease in primary care referrals during 2020, an overcompensation increase in referrals was not observed in 2021. However, the increase in the percentage of patients needing bracing might reflect a delayed initial presentation to the SD consultation.

Emergency Department Use, Hospitalization, and Their Sociodemographic Determinants among Patients with Substance-Related Disorders: A Worldwide Systematic Review and Meta-Analysis

Background: Identifying the determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRD) can help inform healthcare services and case management regarding their unmet health needs and strategies to reduce their acute care. Objectives: The present study aimed to identify sociodemographic characteristics, type of used drug, and risky behaviors associated with ED use and hospitalization among patients with SRD. Methods: Studies in English published from January 1st, 1995 to April 30th, 2022 were searched from PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies on ED use and hospitalization among patients with SRD. Results: Of the 17,348 outputs found, a total of 39 studies met the eligibility criteria. Higher ED use and hospitalization among patients with SRD were associated with a history of homelessness (ED use: OR = 1.93, 95%CI = 1.32–2.83; hospitalization: OR = 1.53, 95%CI = 1.36–1.73) or of injection drug use (ED use: OR = 1.34, 95%CI = 1.13–1.59; hospitalization: OR = 1.42, 95%CI = 1.20–1.69). Being female (OR = 1.24, 95%CI = 1.14–1.35), using methamphetamine (OR = 1.99, 95%CI = 1.24–3.21) and tobacco (OR = 1.25, 95%CI = 1.11–1.42), having HIV (OR = 1.70, 95%CI = 1.47–1.96), a history of incarceration (OR = 1.90, 95%CI = 1.27–2.85) and injury (OR = 2.62, 95%CI = 1.08–6.35) increased ED use only, while having age over 30 years (OR = 1.40, 95%CI = 1.08–1.81) and using cocaine (OR = 1.60, 95%CI = 1.32–1.95) increased hospitalization only among patients with SRD. Conclusions: The finding outline the necessity of developing outreach program and primary care referral for patients with SRD. Establishing a harm reduction program, incorporating needle/syringe exchange programs, and safe injection training with the aim of declining ED use and hospitalization, is likely be another beneficial strategy for patients with SRD.

A rare case of a combined retinal artery and vein occlusion in a young patient

AbstractPurpose: To report a case of combined retinal artery and vein occlusion in a young patient.Methods: A case report.Results: A 37‐year‐old gentleman presented to the Emergency Department with a central scotoma in his right eye for 1 day. He was known to have right amblyopia but had no known past medical illness. He was a chronic smoker. Best corrected visual acuity was 6/45 in the right eye and 6/7.5 in the left eye. His intraocular pressure was 19 (right) and 18 (left) mmHg. Anterior segment examination was normal. His right eye fundus examination revealed retinal ischaemia and edema in the macula area supplied by cilioretinal artery. The inferotemporal vessels were also tortuous, with flame and dot haemorrhages. His left eye was normal. Optical coherence tomography showed inner retinal hyperreflectivity and edema. Fundus fluorescein angiography showed delayed filling of the cilioretinal artery and inferotemporal retinal vein corresponding to the clinical findings. He was diagnosed with a right eye combined cilioretinal artery and inferotemporal branch retinal vein occlusion. An anterior chamber tap was performed immediately to lower intraocular pressure and improve perfusion. The next day, he reported that his vision was clearer (visual acuity 6/20) and the scotoma was smaller in size. Given his young age, we performed a full systemic young‐stroke workup to evaluate his vascular risk factors and rule out thrombophilia. He was found to have newly diagnosed diabetes and hyperlipidemia. His coagulopathy screen was negative. A primary care referral was made for management of his chronic diseases and for smoking cessation support.Conclusions: Combined retinal and venous occlusions are rare and are often associated with significant systemic comorbidities. In a young, healthy patient, it is particularly important to perform detailed investigations to work up its cause, as this could be a harbinger of future ischaemic events.

The impact of inter-clinician electronic consultation in patients diagnosed with atrial fibrillation in primary care.

An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Inter-clinician electronic consultations (e-consultations) program for the general practitioner referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care. To evaluate the effect of a reduced elapsed time to care after a inter-clinician e-consultations program implementation (2013-2019) in comparison with previous in-person consultation (2010-2012) in the outpatient health care management in a Cardiology Department. We included 10,488 patients with AF from 1 January 2010, to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult program (2013-2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any change in therapy advice from cardiologist was directly implemented in this EPD. During the e-consultation period (2013-2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010-2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6± 8.9 vs. 22.5± 8.1 days, p< .001), and an increase of OAC use (61% [95% IC: 19.6%-102.4%], p < .001). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30-.75]) and all-cause mortality (.42 [95% CI: .29-.62]). The OAC reduces the stroke mortality (.15 [95% CI: .06-.39]) and CV mortality (.43 [95% CI: .29-.62]) and all-cause mortality (.23 [95% CI: .17-.31]). A shared EPD-based inter-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke and cardiovascular/all-cause mortality.

The Role of the Neurological Examination in Primary Care Referrals to Neurology.

Low confidence with the neurological examination may contribute to primary care physicians' discomfort with neurology and a low threshold to refer patients. We surveyed primary care physicians in Quebec about their last three referrals to neurology to evaluate what role the neurological examination played in their decision. Twenty-six physicians answered concerning 73 patient referrals. We found that primary care physicians use the neurological examination to reinforce their decision but rarely depend on the findings. Our results suggest that improving history-taking rather than examination skills may have more impact on neurology referrals, influencing quality of referral information above quantity of referrals.

TERAPI FAVIPIRAVIR PADA SUBYEK COVID-19 DERAJAT SEDANG TANPA GANGGUAN LIVER DI RS PUSAT INFEKSI PROF DR SULIANTI SAROSO

The outbreak of the corona virus which first contracted in December 2019 in Wuhan, China; Currently it has been designated by the World Health Organization (WHO) as a pandemic and is known as Corona Virus Infection Disease 2019 (Covid-19). This study aimed to describe the profile of favipiravir therapy in moderate COVID-19 inpatients without liver impairment at Prof. dr. Sulianti Saroso Infection Center Hospital. The design of this study was an observational study conducted retrospectively. All the patients in this research were received favipiravir loading dose of 1600 mg bid on the first day, and 600 mg bid starting on the day-2 of therapy. The results of the research were 81 moderate Covid-19 inpatients without history or recent liver impairment who were hospitalized in the period October 2020 - July 2021 dominating by female gender (56%). Mode of hospital admission were self-referral to Prof. dr. Sulianti Saroso Infection Center Hospital (83%), primary care (Puskesmas) referral (12%), and other hospital referral (5%). There were no comorbidity in 74,1% of the subjects. Among 25,9% subjects with comorbidity, most of the patients suffered from hypertension (29%); hypertension, and cardiovascular disease (17%). diabetes (12%); diabetes and hypertension (12%); Asthma (12). None of the subjects experienced increased in liver transaminases (ALT, AST), nor ALP and total bilirubin. Eighty-one patients were either cured (12%) with negative PCR test results or improved (88%) at the end of the therapy.

I target glicemici alla luce delle nuove linee guida italiane per il trattamento del diabete di tipo 2

Background/aim: different guidelines provide similar, but not identical, therapeutic targets for HbA1c in type 2 diabetes. These targets can also depend on the different pharmacological strategies adopted for intensifying glycemic control. This editorial is aimed at providing a reference for the choice of glycemic targets in patients with type 2 diabetes, as recommended by the new Italian guidelines for the treatment of type 2 diabetes. Methods and results: the present paper revised the recently published Italian guidelines for the treatment of type 2 diabetes (outpatients), either in primary care or specialist referral. The guideline has been developed following the methods described in the Manual of the National Guideline System (http://www.snlg-iss.it) by a panel nominated by the Società Italiana di Diabetologia (SID) and Associazione Medici Diabetologi (AMD).