Referral Base Research Articles

Common variable immunodeficiency clinical manifestations are shaped by presence and type of heterozygous NFKB1 variants.

NFKB1 encodes p105, which is processed to p50 to mediate canonical NF-κB signaling. Though NF-κB is a central driver of inflammation and heterozygous NFKB1 variants are considered the most common monogenic etiologies of common variable immunodeficiency (CVID), few studies have explored how NFKB1 variants shape clinical course or inflammation in CVID. We leveraged a regional cohort of CVID patients with and without heterozygous NFKB1 variants to assess how clinical and inflammatory features of CVID are shaped by the presence of these variants. We compared clinical complications, immunological features, and plasma cytokine levels of 15 CVID patients with heterozygous NFKB1 variants with 77 genetically undefined CVID patients from the same referral base. We also assessed differences between CVID patients with frameshift or nonsense NFKB1 variants compared to those with missense NFKB1 variants. We found CVID patients with heterozygous NFKB1 variants to have increased autoimmune disease, bronchiectasis, gastrointestinal infections, inflammatory bowel disease (IBD), and plasma cytokines. These findings were more pronounced, and included elevation of monocytes, in CVID patients with frameshift or nonsense NFKB1 variants relative to those with missense NFKB1 variants. In a regional cohort, heterozygous NFKB1 variants were associated with worsened CVID clinical course and increased evidence of inflammation in the blood. CVID patients with frameshift or nonsense NFKB1 variants had more significant increases in non-infectious complications and peripheral monocytes than those with missense NFKB1 variants. Presence of pathogenic NFKB1 variants in CVID patients may worsen disease course and warrant closer monitoring.

AHP SO03 - The role of the specialist upper gastrointestinal (UGI) benign dietitian in the management of benign UGI disorders – a review of the outpatient referral base

Abstract Background Benign UGI disorders can negatively affect patients’ nutritional status by impacting on oral intake and/or through malabsorption. GSTT performs a high volume of benign UGI surgeries and is a tertiary referral centre for oesophageal reconstructions and complex hernias. The role of the dedicated specialist UGI benign dietitian was established in 2019 to provide dietetic expertise to the UGI multidisciplinary team (MDT). It supports patients before and after surgery with the aim of reducing post-operative complications, length of hospital stay, re-admissions and improving patient experience and quality of life. Method Outpatient referrals to the UGI benign dietetic service between 02/02/2024 and 06/06/2024 were reviewed for source of referral, reason for dietetic referral and UGI diagnosis. Results Twenty-five new referrals were received from a variety of clinical specialities (table 1). The primary UGI disorders of referrals are outlined in table 2, with complex hernia repair being the most common. Table 3 outlines the broad range referral reasons. Nutrition support referrals were received for the following disorders: achalasia, oesophageal stricture and following oesophageal perforation, hiatus hernia repair, cholecystectomy and oesophagectomy. All weight management referrals were for complex hernia repair patients. Referrals for the side-effects of UGI surgery included dietetic support with pancreatic exocrine insufficiency (pancreatectomy; distal gastrectomy), dumping syndrome (hiatus hernia repair) and delayed gastric emptying (oesophagectomy). Conclusion The role of the benign UGI dietitian requires skills and expertise in a broad range of dietetic interventions. The service is well utilised by surgical and non-surgical colleagues. Next steps for service development would be to review the impact of interventions on surgical and patient reported outcomes, and explore feasibility of patient groups to deliver dietetic advice (for example weight reduction prior to surgery) to improve capacity within the service.

Transition of Care of Stable Kidney Transplant Patients to Referring Nephrologists: A Survey of U.S. Transplant Program Staff.

We conducted a national survey to assess the opinions and experiences of transplant center staff related to processes of care graduation. Following IRB approval, medical staff at U.S. adult kidney transplant programs were surveyed using the Qualtrics survey platform (4/5/2022-10/05/2022). Respondents were invited via email and listservs of professional societies. If > 1 survey was submitted for a program, a selection hierarchy was utilized (e.g., prioritizing nephrologists' responses). Respondents provided data from 46.7% of active programs (N = 92), representing 67% of the national kidney transplant volume. Most respondents (70%) were nephrologists. Full graduation to referring nephrologists was reported by 39% of transplant programs, with an additional 48% reporting partial graduation with ongoing co-management. Rationales for graduation were multifactorial, most commonly including patient travel distance (64%), maintenance of referral base (58%), continuity of care (58%), and center and/or patient burden (54%). Common reasons cited by programs for postgraduation return of care to the transplant center included worsening renal function (82%), malignancy (66%), opportunistic infection (63%), limited local nephrologist availability (60%), and pregnancy planning (57%). Additional coordinators and clinic staff were cited as needed to make transplant center perpetual care feasible by 78% of programs, with 71% stating that more clinicians are needed, while half thought more physical space or telemedicine are required. Graduation of kidney transplant patients is common, with half of programs using a joint-care approach and another third reporting full return of care to the referring nephrologist. Expanded opportunities related to transplant care for the broad nephrology community are essential.

Mental Illness in Refugee and Immigrant Women: A Midwife's Perspective on Culturally Competent Care

The assessment, diagnosis and referral for mental illness management have been recognized as indispensable roles within midwifery practice both in the United States and in Canada. War, civil unrest and natural disasters, have made mental health assessment crucial for refugee and new immigrant women who present as midwifery clients. Since 1991, National Depression Screening Day (NDSD) had been conducted in cities across the United States and Canada using the Harvard Department of Psychiatry National Depression Screening Day Scale (HANDS©). It facilitates the diagnosis of depression based on DSM-IV criteria. The HANDS© tool includes a 10-item interview guide which is a “self-report scale”. HANDS© demonstrated good internal consistency and validity and was 95 percent sensitive.33 Responses could indicate the need for thyroid screening, referral for mental health counselling or psychiatric care. Strategies for transforming midwifery practice are explored: taking a holistic approach, communication strategies, continuing education strategies, documentation and empowerment issues, multidisciplinary team approach, clinic environment issues, resources and referral base. As we develop expertise in the care of torture and trauma survivors, it behooves us to identify the experts amongst our ranks and to refer our clients to these midwives who will best meet their needs. Further research is needed to guide our incorporation of the skills for treating survivors in our educational programs for the midwives of the future.

Ovarian Cancer surgical consideration is markedly improved by the neural network powered-MIA3G multivariate index assay.

Surgery remains the main treatment option for an adnexal mass suspicious of ovarian cancer. The malignancy rate is, however, only 10-15% in women undergoing surgery. This results in a high number of unnecessary surgeries. A surveillance-based approach is recommended to form the basis for surgical referrals. We have previously reported the clinical performance of MIA3G, a deep neural network-based algorithm, for assessing ovarian cancer risk. In this study, we show that MIA3G markedly improves the surgical selection for women presenting with adnexal masses. MIA3G employs seven serum biomarkers, patient age, and menopausal status. Serum samples were collected from 785 women (IQR: 39-55 years) across 12 centers that presented with adnexal masses. MIA3G risk scores were calculated for all subjects in this cohort. Physicians had no access to the MIA3G risk score when deciding upon a surgical referral. The performance of MIA3G for surgery referral was compared to clinical and surgical outcomes. MIA3G was also tested in an independent cohort comprising 29 women across 14 study sites, in which the physicians had access to and utilized MIA3G prior to surgical consideration. When compared to the actual number of surgeries (n = 207), referrals based on the MIA3G score would have reduced surgeries by 62% (n = 79). The reduction was higher in premenopausal patients (77%) and in patients ≤55 years old (70%). In addition, a 431% improvement in malignancy prediction would have been observed if physicians had utilized MIA3G scores for surgery selection. The accuracy of MIA3G referral was 90.00% (CI 87.89-92.11), while only 9.18% accuracy was observed when the MIA3G score was not used. These results were corroborated in an independent multi-site study of 29 patients in which the physicians utilized MIA3G in surgical consideration. The surgery reduction was 87% in this cohort. Moreover, the accuracy and concordance of MIA3G in this independent cohort were each 96.55%. These findings demonstrate that MIA3G markedly augments the physician's decisions for surgical intervention and improves malignancy prediction in women presenting with adnexal masses. MIA3G utilization as a clinical diagnostic tool might help reduce unnecessary surgeries.

Syntax Error: Variations in the Verbiage of Prescription Labels for Pediatric Liquid Medications.

Background Pharmacists can modify prescriptions from prescribers for clarity and patient understanding, provided the confines of the original order are met, yet the verbiage used by pharmacists isnot standardized. Prescription directions for children, especially children eight years old and younger, should be written with the verb "give" instead of "take" as their parents or caregivers are expected to administer them. Errors in prescribing, dispensing, and administering medication comprise a significant portion of preventable medical errors in children. To intervene and assist pharmacies, we must first identify and characterize the problem. This study aimed to determine if there is a relationship between prescribers and pharmacists using the verb "give" or "take" when prescribing and printing prescription labels for pediatric liquid medications. In addition, it aimed to determine if there is a relationship between chain pharmacies and independent pharmacies using the verb "give" or "take" when printing labels for pediatric liquid medications. Methodology The participants in this study were caregivers of children eight years old and younger who had been prescribed a new liquid medication.We recruited prescribers in North Louisiana to serve as a referral base for the study. Caregivers were referred to the study by prescribers. A rubric was created to investigatethe text ofprescription labels. Fisher's exact test was used to determine the relationship between verb choice and prescribers and pharmacists, as well as the relationship between verb choice and chain pharmacies and independent pharmacies. Results A total of 11 (26.83%) prescriber texts used the verb "give," while 12 (29.27%) prescriber texts used the verb "take." Overall, 18 (43.90%) prescriber texts did not use a verb at all. Of these 18 prescriber texts that did not include a verb, 14 prescription labels used the verb "give," and four used the verb "take." In total, 10 (23.81%) chain pharmacy prescription labels used the verb "give," and 10 (23.81%) chain pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between prescribers and pharmacists equaled 0.0001. A total of 19 (46.34%) independent pharmacy prescription labels used the verb "give," and two (4.88%) independent pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between chain pharmacies and independent pharmacies equaled 0.0063. Conclusions The relationship between prescriber texts and pharmacist prescription labels shows a relationship between their verb choice (p = 0.0001). The relationship between chain pharmacy and independent pharmacy prescription labels shows a relationship between their verb choice (p = 0.0063). This study has illuminated how medication orders begin before they are modified, if necessary, for the patient's clarity and understanding. This study can be used to instruct prescribers on writing more accurate prescription instructions to prevent medical errors, and it can help pharmacists recognize potential dangers and prevent them through editing.

(013) How do Sexual Medicine Specialists Handle Patient Counseling and Penile Rehabilitation in Patients Undergoing Robotic Assisted Radical Prostatectomy (ralp): Trends in Pre Op and Post Operative Management

Abstract Introduction Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel has been published in Journal of Sexual Medicine in late 2022. However, evaluation and treatment in this subset of patients appears to be variable and not evidence driven. Objective The objective of our study was to poll sexual medicine specialists regarding their current evaluation and treatment of sexual dysfunction before and after RALP. Methods 22 sexual medicine specialists took a questionnaire at the time of the SMSNA/ISSM meeting in the fall of 2022. Queries were made regarding the demographics of the specialists, their pre operative evaluation, guidance and treatments, and the nature of their referral base. Information was also collected regarding pre operative questions about multiple sexual parameters such as ejaculation, penile curvature, erectile function, climacturia and any initiation of pre op therapies. Post operative questionnaire data included timing of initial evaluation, therapeutic recommendations and likelihood and timing of post operative recovery of function. Results 23 responses were collected. 100% of respondents were SMSNA members, 8 (34.8%) were ISSM members. 22 (95.7%) had a subspecialty practice in sexual medicine. 100% were located in North America. A majority of respondents (19/23, 82.6%) had between 2-10 prostate surgeons in their practice. 9 (39.1%) reported that those surgeons routinely sent patients for preoperative optimization; 4 (17.4%) reported that none did so. 7 (31.8%) regularly counseled patients preoperatively about the risk of ejaculatory pain, 11 (47.8%) about the risk of climacturia, 16 (69.6%) about the risk of penile length loss, 17 (73.9%) about the risk of significant erectile dysfunction, and 7 (30.4%) about the risk of penile curvature. 22 (95.7%) cautioned patients that they would most likely need medication to assist with erectile function postoperatively. For preoperative optimization, 12 (54.5%) respondents regularly recommend preoperative PDE5is, 7 (30.4%) regularly recommend a vacuum erection device, and 3 (13%) recommend pelvic floor rehabilitation. Postoperatively, 13 (56.5%) recommend a vacuum device postoperatively, another 3 (13%) sometimes do so, and 19 (82.6%) encouraged patients to start PDE5is immediately postoperatively. 19 (82.6%) continued PDE5is after 3 months without spontaneous erections. 17 (73.9%) recommended Tadalafil 5mg daily, others used Sildenafil at varying doses. 15 (65.2%) respondents believed that penile rehabilitation made a difference in outcomes at 2 years. Another 5 (21.7%) were unsure, but had enough data to continue with their protocol. Conclusions Despite new guidelines for evaluation and treatment of patients undergoing RALP, there appears to be diverse counseling, recommendations and treatment both preoperatively and postoperatively. Evidence based and expert opinion guidelines may alter pre operative counseling and treatment in the future. Disclosure No.

Assessment of Patient Referrals with Large Numbers of Non-pedunculated Colorectal Lesions

Background: Large (≥20mm) non-pedunculated colorectal lesions are frequently referred to specialty centers for endoscopic resection. These lesions are technically challenging to resectand associated with substantially greater risk than smaller lesions. Patients with such polypsoften have synchronous lesions. We sought to identify evidence for whether synchronouslesions were sometimes the true basis for referral of large non-pedunculated colorectal polypsfrom community endoscopists to a tertiary center.
 Methods: We utilized a prospectively collected database of 1356 consecutive referred patients to an expert colonoscopist at our tertiary center between August 2019 and May 2023. We identified patients with ≥30 precancerous lesions resected from the colorectum during their first two colonoscopies at our center. Patients in the database with the same gender, within 3 yearsof age, and with the same location (proximal vs. distal colon) of the index large lesion referred for resection were identified as controls. Groups were compared for the size of index lesion, number of polyps resected by both centers, and size of polyps resected.
 Results: Among 1356 patients, 49 (3.6%) had ≥30 precancerous lesions resected at our center. Compared to controls, the index lesion was smaller in patients with ≥30 lesions (mean 28.9mmvs 23.3mm). Among patients with ≥30 synchronous polyps, the referring physician resected 10.6% of all synchronous lesions, compared to 47.8% in the control group (p<0.0001). Inpatients with ≥30 lesions, 84% of all synchronous lesions were <10mm, 15% were 10-19mm, and only 1% were >20mm.
 Conclusion: Our results suggest a subset of patients with large non-pedunculated colorectal precancerous lesions referred to tertiary centers are referred because of the number of lesions present, rather than technical challenges associated with resection of individual lesions. The rationale for these referrals is uncertain. It may lie in the reimbursement system, which only compensates physicians for the first polypectomy.

A multidisciplinary dermatology-gastroenterology-rheumatology (DER.RE.GA) unit for the care of patients with immune-mediated inflammatory diseases: analysis of the first 5 years from the dermatologist’s perspective

Immune-mediated inflammatory diseases (IMIDs) constitute a heterogenous group of chronic and highly disabling conditions. The clinical challenges they often pose led to formation of numerous dermo-rheumatological interdisciplinary units around the world, which are reported to benefit their patients in various ways. The present paper describes our experience with a multidisciplinary dermatology-rheumatology-gastroenterology unit DERREGA at the IRCCS Foundation Policlinico San Matteo of Pavia over a period of 5 years of its activity (2017–2022). A digital database was created, containing the medical records of 146 patients referred to the dermatology unit only by rheumatologists or gastroenterologists belonging to the multidisciplinary unit DERREGA. Then, aspects such as demographics, initial basis of referral and final diagnosis among the patients were analyzed retrospectively. Patients were classified as either gastroenterological or rheumatological, and then categorized according to the specific basis of referral. Most of the gastroenterological patients (97%) were affected by inflammatory bowel diseases (IBDs). Rheumatological patients were divided in three subgroups, including patients referred with vasculitis, arthropathies (undifferentiated arthritis, psoriatic arthritis and other arthritis) and other rheumatological diseases. Then, final diagnoses were evaluated in each group. Almost a third of IBD patients received a diagnosis of paradoxical psoriasis. Dermatological examination allowed diagnosis of minimal psoriasis based on Caspar criteria in over 70% of the patients admitted with undifferentiated arthritis. A multidisciplinary approach is suggested to provide more effective management of IMIDs and, specifically, from a dermatological perspective, allows for the diagnosis of minimal manifestations of psoriasis in patients with a provisional diagnosis of undifferentiated arthritis.

Association between the stage of labour during caesarean delivery with adverse maternal and neonatal outcomes among referred mothers to tertiary centres in resource-limited settings

ObjectiveAlthough the caesarean delivery (CD) rate has substantially increased, little is known about its impacts when performed in the first and second stages of labour on fetomaternal outcomes, especially among...

Cardiac troponin T and I are differentially associated with myocardial fibrosis assessed by cardiac magnetic resonance imaging

Abstract Background Cardiac troponin T (cTnT) is more potently associated with non-cardiovascular (CV) mortality and cardiac troponin I (cTnI) is more specific for CV risk in the general population. Cardiovascular magnetic resonance imaging (CMR) measurement of extracellular volume (ECV) allows for assessment of diffuse myocardial fibrosis and is associated with adverse CV events. Focal myocardial scars are assessed by late gadolinium enhancement (LGE) and LGE scar presence is associated with unfavorable CV outcomes. The distinct clinical outcomes associated with cTnT and cTnI may be due to different subtypes and burden of myocardial fibrosis. Elevation of cTnT associates with increased ECV in a CMR referral base and with nonischemic myocardial scars in the general population. There is limited data comparing the associations of cTnT and cTnI with CMR indices of fibrosis in the general population. Purpose Perform head-to-head comparison of the associations of cTnT (Roche Elecsys) and cTnI (Abbott Alinity) with diffuse and focal myocardial fibrosis assessed by CMR. Methods Two hundred community-dwellers born in 1950 with approximately similar sex distribution were recruited. All participants were without contraindications to contrast-enhanced CMR, had normal kidney function and no known coronary artery disease. For the study a 1.5-T Philips MRI clinical scanner was used. Diffuse fibrosis was estimated by septal ECV and focal scars were quantified by LGE and classified as either ischemic or nonischemic. Complete MOLLI-sequence for assessment of ECV was present in 192 participants and 198 participants had complete LGE sequence. Logistic regression analysis was used to examine relationships between log transformed cardiac troponins and CMR indices of myocardial fibrosis, adjusting for a priori selected established cardiovascular risk factors. We analyzed ECV according to cut-off values based on the upper sex-specific quartile. Results The median age was 69 (68.6-69.3) and 52% were male (Table 1). The upper sex-specific quartile of ECV was 27% for men and 28% for women. cTnT was associated with ECV in the fully adjusted model (odds ratio [OR] 1.98, 95% CI 1.08-3.64), in contrast to cTnI which was not associated with ECV in any of the models (Table 2). cTnT (OR 3.71 95% CI 1.83-7.50) and cTnI (OR 1.69 95% CI 1.24-2.30) were associated with the presence of any LGE scar in the fully adjusted model, but the association was stronger for cTnT (p for comparison = 0.024). cTnT and cTnI were significantly associated with nonischemic scars in all models (Table 2), but stronger for cTnT (p for comparison = 0.018). In the fully adjusted model only cTnI was associated with the presence of ischemic scars (OR 1.66 95% CI 1.05-2.61). Conclusion(s) In our cohort of community-dwellers, cTnT is the stronger marker of diffuse and nonischemic myocardial fibrosis, while cTnI seems to more strongly reflect the presence of ischemic scar as assessed by CMR.Participant characteristicsAssociations of cTnT and cTnI

The Significance of a “MGUS” Tumor Board

Our large academic medical center consists of both a main campus and several regional sites that all offer hematology/oncology services where monoclonal gammopathy cases are referred for consultation. We receive well over 100 requests annually to see cases with abnormal monoclonal proteins. The challenge was how to triage these requests, with the goal of improving patient access to main campus myeloma experts while improving patient care and timely management. We decided to schedule cases initially referred for monoclonal gammopathy of undetermined significance (MGUS) with our advanced practice providers (APPs) both in the region and at main campus. Due to the concern for varying experience managing MGUS, differences in diagnostic practice and limited guidance we developed a novel concept to have a tumor board to review MGUS cases that were initially seen by our APPs. The “MGUS” tumor board is ran by three of our main campus myeloma focused hematologists and our myeloma dedicated APRN-PhD. We meet twice a month to review cases. Over the past 2 years we reviewed 147 cases providing recommendations for further work up. Of these, 41 cases (28%) were found to have a clinically significant monoclonal protein necessitating referral to a physician at main campus. The breakdown of these cases are detailed below in T able 1. Sixteen patients (11%) were started on treatment, the other 25 (17%) remained on observation. Another aspect of the tumor board is to provide education regarding clinically significant scenarios that involve monoclonal proteins. This tumor board offers CME credit for both APPs and physicians. By developing a team of knowledgeable APPs we have shifted 72% of monoclonal gammopathy referrals to remain under the care of APPs which improved access to main campus myeloma physician experts. This allowed the myeloma team at main campus to see more second opinions, open more clinical trials and expand our cell-therapy options for patients. Our referral base has grown and we have hired more APPs in the region and two additional myeloma physicians at main campus since starting the “MGUS” tumor board. Overall, we were successful in transitioning “MGUS” referrals to our APPs, but there were higher than expected percent of patients with clinically significant monoclonal proteins. Our data shows that it is essential for there to be some standardization for reviewing and working up “MGUS” referrals. This is especially important at large centers with multiple regional locations. We recommend a tumor board style review as it allows for discussion and education of “MGUS” referrals which prove to be far more complex in many cases.

Abstract 218: Evaluating Thrombectomy Candidacy in Large Core Strokes: Lessons from the SELECT2 Trial at Our Institution

Introduction Reperfusion therapy for patients with large vessel occlusion stroke includes thrombolytics and mechanical thrombectomy. Candidacy for thrombectomy depends on patient factors under active investigation. Historically, patients with large strokes have been excluded from major trials evaluating thrombectomy due to concern that thrombectomy would pose considerable risk with limited benefit. However, new evidence from the Select‐2 Trial found improved modified Rankin scale scores and higher rates of functional independence at 90 days following large stroke in patients who underwent thrombectomy versus medical therapy alone. We explored if patients presenting with large stroke at our institution resemble those in the Select‐2 Trial and, how many previously excluded patients could have possibly benefitted from thrombectomy. Methods Patients presenting as a code stroke at our institution from 1/2022 to 7/2022 were retrospectively analyzed. Large strokes, defined as CTP volume greater than 50mL, were identified. Background information included age, sex, race, and prior stroke. Regarding patient stroke presentation, the following data were gathered: NIHSS, LVO status, CTA results, CTP, tPA, thrombectomy status, TICI score, and discharge status. Our patients included in this study were compared to the patients included the Select‐2 Trial. Mortality rates and NIHSS at discharge were compared between thrombectomized and non‐thrombectomized patients at our institution. Results Of the 365 code strokes activated at our institution during the study period, 26 met criteria for a large stroke. Of those 26, 13 met all criteria for inclusion in SELECT‐2. Only 9 of the 26 patients received thrombectomy, including 7 of 13 patients otherwise meeting SELECT‐2 criteria. 6 patients were excluded from thrombectomy who would have met criteria for SELECT‐2. Of the 9 who underwent thrombectomy, one expired, and the average NIHSS calculated from physical exam at discharge of surviving patients was 13. Of the 17 who did not undergo thrombectomy, seven expired and the average NIHSS at discharge was 19.4. Of large stroke patients, average age was 69.5 years (SD 11.0), similar to Select‐2 (median age 66). Average NIHSS at presentation was 19 (SD 6.55), similar to Select 2. Compared to SELECT2 enrollment, our patients were more likely to be female (50% vs 41%), Black (50% vs 25%), have a history of prior stroke (38% vs. 9%). LVO was identified on 23 of 26 patients. Of these 23, 17 MCA, 3 ACA, 6 ICA, and 2 carotid terminus occlusions were identified (6 had tandem occlusions). The average rCBF volume was 102.3 mL (SD 64.3) compared to median estimated ischemic core volume of 80mL in Select 2. Conclusion The patients presenting to our institution with large stroke resemble those included in the Select 2 trial, which demonstrates positive outcomes following mechanical thrombectomy for this special population. Patients with large strokes are frequently excluded from receiving treatment with mechanical thrombectomy. Analysis of a larger data set, including large stroke patients from 2018 to 2022, is currently pending. In light of the Select 2 trial, patients in our community and in our referral basis stand to benefit from an institutional practice of offering thrombectomy to those presenting with large stroke.

Clinical Identification of Tongue Cancer: A Case Report Series

Background: Dentists play an important role in oral cancer case finding. Dentists in the first line of healthcare can make identification through history taking and clinical examination. 
 Case(s): The first case; a 40-year-old female complained of tongue ulcers sinces 2 months. The patient had articulation changes and clinical examination results of T2 N2a. The second case; 43-year-old male complained of tongue ulcers sinces 5 months. The patient had articulation changes and the clinical examination result was T2 N2a. The third case; 65-year-old male complained of tongue ulcers sinces 2 years. The patient had changes in articulation and clinical examination results T2 N2a. All patients were referred to an oncological surgeon.
 Conclusion: The change in the patient's voice, the discovery of extraoral lymphadenopathy (N), and the description of intraoral lesions (T), formed the basis of the patient's referral to an oncological surgeon.

Implementing a guideline-based education and exercise program for people with knee and hip osteoarthritis-Practical experiences of providers and clinic leaders: Aqualitative study.

The Good Life with osteoArthritis: Denmark (GLA:DTM ) program is an evidence-based education and exercise program designed for individuals with symptomatic hip and knee osteoarthritis. Launched in Denmark, it has been implemented across Europe, Australia, and North America. The authors assessed the feasibility of GLADTM implementation in Canada (Alberta) by applying the RE-AIM framework. An evaluation objective was to identify factors impacting the implementation of the program in both publicly funded and private rehabilitation settings, based on the experience of the initial cohort of providers and clinic leaders who set up and delivered the program. Semi-structured telephone interviews were conducted with GLA:DTM -trained providers, managers, or directors of clinics across Alberta. Braun and Clarke's thematic approach was used to code the data and identify emergent categories and themes. Those relevant to the implementation were identified and by consensus, categorized as facilitators of and challenges to the implementation process. Eighteen GLA:DTM -trained providers and three clinic leaders from a range of clinical settings completed an interview. Seven common themes emerged in relation to implementation across the study settings. Three themes reflect facilitators of implementation (program acceptability by providers, multi-level support mechanisms, and program flexibility) and four implementation challenges (direct and indirect costs, lack of external referrals, program access issues, and lack of suitable space). The initial implementation of the program was exploratory with limited focus on long-term sustainability. The GLA:DTM program is a translatable program that can be implemented with relative ease in both public and private rehabilitation settings; however, costs, space constraints, and having an adequate referral base were noted challenges. Further work is warranted to explore equitable access across public and private settings and program sustainability.

The ICC’s investigation into the situation in Ukraine on the basis of referrals by third states parties to the Rome Statute: A commentary

Summary This commentary discusses the decision taken by the Prosecutor of the International Criminal Court (ICC) to open an investigation into the situation in Ukraine on the basis of referrals by a number of state parties to the Rome Statute. In particular, it is interested in the prior decision that the Prosecutor had to make and actually made for that move to be procedurally possible. Indeed, the Prosecutor had to renounce to his steps towards an investigation proprio motu, i.e. on his own initiative. The most important of these steps was the request of judicial authorisation by the ICC Pre-trial Chamber. This commentary argues that for that reason, the Prosecutor’s decision was ill-advised, despite being in conformity with the Rome Statute. It argues that in that specific situation where neither Ukraine nor the Russian Federation are parties to the Rome Statute and where the Security Council has not and could not play its Rome Statute role, judicial oversight was an important – arguably the most important – legitimising factor for the investigation. The Office of the Prosecutor (OTP) could therefore not have neglected it. Going into the details of the starting investigation, the commentary also weighs the pros and cons of the Prosecutor’s decision. In other words, it balances what was actually lost and what was supposed to be gained by way of that change of procedural paths to investigation.

Factors Influencing Receipt and Type of Therapy Services in the NICU.

Understanding the type and frequency of current neonatal intensive care unit (NICU) therapy services and predictors of referral for therapy services is a crucial first step to supporting positive long-term outcomes in very preterm infants. This study enrolled 83 very preterm infants (<32 weeks, gestational age mean 26.5 ± 2.0 weeks; 38 male) from a longitudinal clinical trial. Race, neonatal medical index, neuroimaging, and frequency of therapy sessions were extracted from medical records. The Test of Infant Motor Performance and the General Movement Assessment were administered. Average weekly sessions of occupational therapy, physical therapy, and speech therapy were significantly different by type, but the magnitude and direction of the difference depended upon the discharge week. Infants at high risk for cerebral palsy based on their baseline General Movements Assessment scores received more therapy sessions than infants at low risk for cerebral palsy. Baseline General Movements Assessment was related to the mean number of occupational therapy sessions but not physical therapy or speech therapy sessions. Neonatal Medical Index scores and Test of Infant Motor Performance scores were not predictive of combined therapy services. Medical and developmental risk factors, as well as outcomes from therapy assessments, should be the basis for referral for therapy services in the neonatal intensive care unit.

Dietitian and nutrition-related practices and resources in Australian and New Zealand PICUs: A clinician survey

BackgroundRecommendations to facilitate evidence-based nutrition provision for critically ill children exist and indicate the importance of nutrition in this population. Despite these recommendations, it is currently unknown how well Australian and New Zealand (ANZ) paediatric intensive care units (PICUs) are equipped to provide nutrition care. ObjectivesThe objectives of this project were to describe the dietitian and nutrition-related practices and resources in ANZ PICUs. MethodsA clinician survey was completed as a component of an observational study across nine ANZ PICUs in June 2021. The online survey comprised 31 questions. Data points included reporting on dietetics resourcing, local feeding-related guidelines and algorithms, nutrition screening and assessment practices, anthropometry practices, and indirect calorimetry (IC) device availability and local technical expertise. Data are presented as frequency (%), mean (standard deviation), or median (interquartile range). ResultsSurvey responses were received from all nine participating sites. Dietetics staffing per available PICU bed ranged from 0.01 to 0.07 full-time equivalent (median: 0.03 [interquartile range: 0.02–0.04]). Nutrition screening was established in three (33%) units, all of which used the Paediatric Nutrition Screening Tool. Dietitians consulted all appropriate patients (or where capacity allowed) in six (66%) units and on a request or referral basis only in three (33%) units. All units possessed a local feeding guideline or algorithm. An IC device was available in two (22%) PICUs and was used in one of these units. ConclusionsThis is the first study to describe the dietitian and nutrition-related practices and resources of ANZ PICUs. Areas for potential improvement include dietetics full-time equivalent, routine nutrition assessment, and access to IC.

The Role of Genetic Testing in Avoiding Diagnostic Delays in Inherited Retinal Disease.

To identify and highlight potential delays in diagnosis and improve the characterization of the providers referring individuals affected with suspected IRDs for specialty care, we performed an analysis of the patients with IRDs seen by an ophthalmic genetics specialty service. In addition, we analyzed the diagnostic yield of genetic testing in patients with IRD in our series and compared this information with other previous studies. We analyzed 131 consecutive patients with suspected IRDs referred to an ophthalmic genetics specialty service at a tertiary hospital. Provider referral patterns, delays in diagnosis and the diagnostic yield of genetic testing were evaluated. Mean age in the cohort was 24 years. From the 51 patients that underwent genetic testing, the diagnostic yield was 69%. Of these, genetic testing revealed 51% of patients had an incorrect initial referral clinical diagnosis. The average delay to reach a correct diagnosis was 15 years. Ophthalmologists represented the largest referral base at 80%, followed by neurologists representing 5% of referrals. Pediatric and retinal specialists were the largest referral of ophthalmic subspecialties at 44% and 35%, respectively. A significant number of patients experienced a prolonged delay in reaching a correct diagnosis largely due to a delay in initiating the genetic evaluation and testing process. The initial suspected clinical diagnosis was incorrect in a significant number of cases, revealing that affected patients were potentially denied from appropriate recurrence risk counseling, relevant educational resources, specialty referrals in syndromic cases, and clinical trial eligibility in a timely manner.

Efficacy of optical coherence tomography in the triage of women with minor abnormal cervical cytology before colposcopy.

To evaluate the efficacy of Optical Coherence Tomography (OCT) for detecting cervical lesions in women with minor abnormal cytology results (atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL)). A prospective study was conducted at gynecologic clinic from Mar 2021 to Sep 2021. The recruited women with cervical cytological findings of ASC-US or LSIL were inspected with OCT before colposcopy-directed cervical biopsy. The diagnostic performance of OCT, alone and in combination with high-risk human papillomavirus (hrHPV) testing were evaluated to detect cervical intraepithelial neoplasia of grade 2 or worse (CIN2+)/CIN3 or worse (CIN3+). The rate of colposcopy referral and the immediate risk of CIN3+ of OCT were calculated. A total of 349 women with minor abnormal cervical cytology results were enrolled. For detection of CIN2+/CIN3+, the sensitivity and NPV of OCT were lower than those of hrHPV testing (CIN2+: 71.3% vs. 95.4%, 89.0% vs. 91.1%, P < 0.001; CIN3+: 75% vs. 93.8%, 96.5% vs. 95.6%, P < 0.001), but the specificity, accuracy and PPV were higher than those of hrHPV testing (CIN2+: 77.5% vs. 15.6%, 75.9% vs. 35.5%, 51.2% vs. 27.3%, P < 0.001; CIN3+: 69.4% vs. 13.6%, 69.9% vs. 20.9%, 19.8% vs. 9.9%, P < 0.001). OCT combined with hrHPV testing (CIN2+: 80.9%; CIN3+: 72.6%) showed higher specificity than that of OCT alone (P < 0.001). The colposcopy referral rate base on OCT classification was lower than that based on hrHPV testing (34.7% vs. 87.1%, P < 0.001). Patients with hrHPV-positive ASC-US and hrHPV-negative LSIL cytology, the immediate CIN3+ risk in OCT negative cases was less than 4%. OCT alone or combination with hrHPV testing shows good performance for detecting CIN2+/CIN3+ in patients with ASC-US/LSIL cytology. OCT is an effective method for colposcopy triage in women with hrHPV-positive ASC-US and hrHPV-negative LSIL cytology.