Referral For Further Evaluation Research Articles

IJCM_33A: Comprehensive Women’s Wellness and Family Welfare Clinic: A Promising Approach for Holistic Healthcare in PGIMER Satellite Sangrur, Punjab

Background: Women’s health disparities, often rooted in sociocultural discrimination, prompted the establishment of the ‘Women’s Wellness and Family Welfare Clinic.’ Objective: The objective of this clinic was to address the adolescents and women-related issues, screening, counselling, mental health, diet and nutrition and, family planning services under one roof. Methodology: The initiative was launched in September 2023 with collaborative efforts between the Department of Community Medicine & SPH and the Department of Gynaecology and Obstetrics at the PGIMER satellite center in Sangrur, Punjab. The clinic comprehensively, recorded socio-demographic profiles, clinical histories and various health dimensions, including physical parameters, mental well-being, social factors, NCD risks, and family planning. Positive screening results prompted referrals for further evaluation. Results: A total of 252 participants underwent screening, of whom 98 (38.9%) were aged 30-39, 32 (12.7%) were planning pregnancy, and 146 (57.6%) were using contraception, with tubal ligation being a prevalent choice 64 (43.4%). Beyond gynaecological concerns, participants reported chronic lower backache (59; 23.4%) and numbness of hands or feet (56; 22.2%) as common symptoms. More than one-third, 96 (39.09%), were found to be at risk for non-communicable diseases (NCDs), with 19 (7.5%) having hypertension, 10 (3.9%) with pre- diabetes/diabetes, and 5 (2%) presenting with breast lumps. Visual Inspection with Acetic Acid (VIA) revealed a 1.2% positivity rate among 117 participants. However, 161 (63%) participants had a BMI over 25, and 121 (48%) consumed fried snacks daily. Domestic abuse was reported by a mere 2 (0.4%) participants, shedding light on the clinic’s potential role in uncovering hidden health issues. Conclusion: The success of this initiative underscores the feasibility of the model wellness clinic in an evolving phase of satellite centre. By offering comprehensive health assessments and facilitating timely referrals, the clinic stands as a promising approach to enhance early detection and treatment, contributing to the holistic well-being of women.

Blood Donor Counselling, Notification, and Referral: Experience from a Tertiary Care Hospital of North India

ABSTRACT Background and Objectives: The concept of blood donor notification and counseling has gained recognition as an essential component of blood safety and donor care. By examining the effectiveness, feasibility, and acceptability of this intervention, valuable insights can be gained to inform future improvements in practices in the region and around the globe. Methods: This retrospective study was conducted at department of transfusion medicine on 18197 consecutive whole blood & component donors who visited the blood Centre between April 2018 and January 2023. The intervention involved the implementation of a blood donor notification and counseling system. Result: 178 donors were reactive in the study period with prevalence rate of (0.9%).112 (62.9%) donors out of 178 seroreactive donors could be contacted telephonically from the blood Centre. These are called as notified donors. Remaining 66 seroreactive donors could not be contacted. 39 donors out of 178 seroreactive donors were responders and remaining 139 donors were non-responders. Conclusion: This study highlights the significance of an efficient and comprehensive donor referral and notification system in ensuring the safety of blood transfusions but still lot of ground work needs to be done. Effective communication, personalized counseling, and continuous education form pillars of this process. The prevalence of transfusion-transmissible infections among blood donors further emphasizes the need for prompt action and appropriate referral for further evaluation and care.

Early Identification of Cognitive Impairment: Utility of the Mini-Cog in Non-Clinical Settings.

While we currently cannot cure Alzheimer's disease or change the course of the disease, there are advantages to early detection. Routine, evidence based, brief cognitive screens offer destigmatized opportunities for diagnosis and improve the possibility of early identification of cognitive impairment. This community-based participatory research project evaluated the use of the Mini-Cog™ instrument to detect cognitive impairment in vulnerable community-dwelling older adults when administered by trained social services providers. Over 9months, a case manager screened 69 clients ages 65 to 94 (mean 74.67) who met inclusion criteria for the pilot; 84.1% were female, 53.6% were Black, 26% were living with undetected cognitive impairment. Although participants agreed to Mini-Cog™ screening, two-thirds with Mini-Cog™ scores indicating cognitive impairment refused referrals for further evaluation. Future interventions should reduce stigma by educating the public about dementia and engaging members of racial and cultural communities in outreach.

Radiological findings in brain MRI scans in youth with early-onset psychosis: A controlled study

There is a lack of consensus on whether routine brain magnetic resonance imaging (MRI) should be recommended as part of the initial assessment in patients with psychosis. No study so far has qualitatively assessed brain MRI in patients with early-onset psychosis (EOP), in whom neurodevelopmental factors may play a stronger role. We aimed to determine the prevalence of brain MRI findings in patients with EOP compared to healthy controls, and assess whether these findings were clinically relevant. Retrospective clinical chart review of all patients with EOP in whom a brain MRI scan was acquired during admission to an inpatient child and adolescent psychiatry unit during January 2013–December 2017, compared to age and biologically assigned gender matched healthy controls. Between group analyses tested differences in rates of qualitatively abnormal MRI scans and changes in clinical management as a result of radiological findings. A total of 256 individuals were included (128 patients with EOP and 128 healthy controls). Patients with EOP presented with a significantly higher rate of abnormal MRI scans relative to healthy controls (21.9% vs 11.7%, p = .030; OR = 2.11, [95% CI:1.06–4.17]). Radiological findings in the EOP group triggered clinical referral for further evaluation or management more often than in the healthy control group (7.0% vs 1.6%, p = .030; OR = 4.76, [95% CI:1.01–22.50]). MRI scans in youth with EOP may be characterized by an increased number of radiological abnormalities than in controls. The rates of MRI findings requiring clinical referral suggests that routine MRI acquisition may need to be considered in patients with EOP.

S3279 A Rare Case of Late Metastatic Disease From Granulosa Cell Tumor as a Solitary Hepatic Mass

Introduction: Granulosa Cell Tumor (GCT) is a rare type of sex cord-stromal neoplasm that often has an indolent course. These tumors make up 2-5% of all ovarian malignancies. When they do metastasize, it is often within the lower abdomen and pelvis. Recurrence of the disease often occurs within 10 years of the diagnosis, but there is potential for recurrent disease beyond this timeframe. Because of the risk of late recurrence with GCT, continued surveillance is crucial beyond surgical resection of the primary tumor. Inhibin has been shown to be a valid marker in both management of primary disease and surveillance for late recurrence. The overall prognosis for GCT is generally favorable given that the disease is detected early. Surgical intervention is mainstay of treatment for these tumors, although systemic chemotherapy is considered in nonresectable or advanced cases. Case Description/Methods: A 53-year-old female with a past medical history of bilateral GCT of the ovaries status post bilateral salpingo-oophorectomy (2009), gastroesophageal reflux disease, and Hepatitis C presented to the emergency department with lower abdominal pain and occasional hematochezia in 2021. She was discharged with referrals for further evaluation. During her work up, she underwent a CT scan that revealed a 4.3 x 3.4 cm exophytic mass in the right lobe of the liver. Further evaluation with MRI showed that the mass was irregular and exophytic with minimally increased size, now measuring 4.6 x 3.7 cm. A CT-guided biopsy showed that the tumor was positive for inhibin, suggestive of metastatic GCT. The solitary hepatic metastasis was treated with microwave ablation. (Figure) Discussion: GCTs are a rare subtype of sex-cord stromal tumor that are typically primary ovarian neoplasms and often have an indolent course and favorable prognosis, although there is evidence that metastatic disease can occur at distant sites and greater than 10 years after diagnosis and surgical resection of the primary tumor. This case describes the recurrence of disease as a solitary hepatic mass. Diagnostic confirmation was made by CT-guided biopsy that found the presence of inhibin, a protein known to be produced by GCT. This case highlights the importance of long-term surveillance in patients with a history of GCT beyond surgical resection and undetectable disease activity.Figure 1.: MRI of the abdomen showing metastatic granulosa cell tumor (arrow).

Examining early intervention referral patterns in neonatal intensive care unit follow up clinics using telemedicine during COVID-19

BackgroundNeonatal intensive care unit (NICU) follow up programs are in place to ensure infant health and development are monitored after discharge. The COVID-19 Public Health Epidemic (PHE) negatively impacted the ability to conduct in-person NICU follow up visits. AimsThis study examines using telemedicine in NICU follow up clinics and compares the rates of referral for further medical and/or educational developmental evaluation. A second objective of the study examines if telemedicine can be implemented in the future to ensure access to families while maintaining high levels of caregiver satisfaction. MethodData were obtained retrospectively from clinical records from one state's NICU follow-up program. Patterns of referral for further developmental evaluation and caregiver satisfaction prior to the COVID-19 PHE and during the first year of the COVID-19 PHE were examined. A total of 658 NICU follow up visits (384 in-person and 274 telemedicine) were included. ResultsChi Square analyses revealed significantly more medically related referrals were made during telemedicine visits compared to in-person visits, χ2 (1) = 5.55, p .05. There were no significant differences between the clinic types in the number of educationally based referrals made, χ2 (1) = 0.028, p > .05. ConclusionThe rates of referral for further evaluation made from in-person and telemedicine clinics were comparable, and caregivers were highly satisfied with telemedicine clinic visits. NICU follow up via a virtual platform saves time, money and is equally effective or better in identifying the need for referral for further evaluation.

Performance of artificial intelligence-based breast cancer screening in a community setting: a real-world evaluation study

Despite improvements in treatment strategies, breast cancer survival rates in India remain low because of poor awareness and advanced stages at presentation. Early diagnosis and treatment can improve the survival rates of patients with breast cancer. A population-based breast cancer screening programme with mammography is often not feasible in resource-constrained settings. Thermalytix, a novel breast cancer screening technology, applies artificial intelligence algorithms over thermal images to generate an automated interpretation report indicating breast health. The Thermalytix testing equipment is portable, requires minimal skills to operate, and operation is 20 times less expensive than a mammography. The test has been used to screen women in community settings in India. This study was done to assess the performance of the Thermalytix test in identifying women suspicious of breast cancer in community settings. Women who underwent Thermalytix tests in community-based screening camps in the Indian states of Karnataka and Maharashtra between Aug 12, 2017, and May 31, 2021, were included in this study. The Thermalytix test captured five thermal images in multiple views from each participant and the tool automatically generated a triage report. A more detailed report with annotations of probably abnormal regions and an overall breast health score ranging from 0 to 5 (B-score) was also generated. A B-score of 4 or 5 on triage indicates a high level of concern and prompts a recommendation to follow-up with breast ultrasonography. A B-score of 3 prompts a recommendation to repeat the Thermalytix test after 3 months. A B-score of 1 or 2 indicates thermal patterns of low level, usually prompting a recommendation to continue routine screening. Participants with B-scores of 4 or 5 on the Thermalytix test were followed-up with a telephone call to obtain information about their subsequent tests, such as mammography, ultrasonography, or histopathological examination. Women with a follow-up report were categorised as having "Normal", "Abnormal-Benign", or "Abnormal-Malignant" findings (as per their Breast Imaging Reporting and Data System score of 1, 2 or 3, or 4 or 5, respectively). 13 932 women were included in the analysis. 775 women complained of a breast lump, 625 (4·5%) of whom were given B-scores of 4 or 5 after Thermalytix testing and were referred for follow-up breast ultrasonography. 117 (18·7%) of these 625 women underwent standard follow-up investigations. Abnormalities were detected in 78 of the 117 followed-up women (74 benign and four malignant breast lesions), indicating that Thermalytix has a positive predictive value of 66·7% in detecting benign and malignant breast lesions. In resource-constrained countries where systematic screening programmes with mammography is not scalable or feasible, the portable, radiation-free Thermalytix test is a promising option for affordable and accessible breast cancer screening. This screening test is not resource-intensive and can be set up in remote locations and operated with minimal training. The Thermalytix test can be used to triage women for referral for further evaluation in secondary or tertiary health-care centres, which makes it a logistically and economically feasible option for breast cancer screening in low-income and middle-income countries. This programme was sponsored by Niramai Health Analytix and was executed in collaboration with National Health Mission, Maharashtra, India, and Bruhat Bengaluru Mahanagara Palike, Municipal Corporation of Bangalore City, Karnataka, India.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management - A review.

Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of "mild traumatic brain injury" or "concussion" or "pursuit" or "accommodation" or "vergence" or "convergence insufficiency" or "saccades" or "vestibulo-ocular reflex" or "vestibular ocular motor screen" or "vestibular rehabilitation", or "vision rehabilitation" including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Improving Anxiety Screening in Patients with Turner Syndrome

Introduction: Turner syndrome (TS) results from a complete or partial loss of the X chromosome and affects 25–50 per 100,000 females. These individuals have characteristic neurocognitive and psychological profiles with an increased lifetime prevalence of mood disorders, such as depression and anxiety. Consensus guidelines recommend the use of psychometrically robust tools to screen for these conditions [Eur J Endocrinol. 2017;177(3):G1–G70 and Gynecol Endocrinol. 2004;19(6):313–9]. We propose a sustainable and informative approach to routine anxiety screening in individuals with TS and describe the prevalence of anxiety, genotype-phenotype associations, and impact of comorbidities on anxiety. Methods: We pilot the use of a self-administered version of the validated Pediatric, Parent Proxy, and Adult Patient-Reported Outcomes Measurement Information System (PROMIS®) Anxiety tool during routine visits to the Cincinnati Children’s Hospital Medical Center (CCHMC) TS clinic from October 2019 to March 2020. Results: Ninety-two eligible TS females, ages 8–62 years, received the PROMIS® Anxiety measure. Elevated anxiety scores, ≥1 standard deviation above the T-score mean, were present in 65% of patients (38% mild, 19% moderate, and 8% severe). Results were discussed during the clinic visit, and referral for further evaluation and treatment was offered. There was no apparent genotype-phenotype association among females with anxiety; however, there appeared to be elevated anxiety symptoms (T-score >60) in those with hearing deficits and also in individuals with three or more medical comorbidities. Of the 55% of patients who filled out the acceptability survey, 88% found the process helpful and ∼50% felt that screening should be performed at least every 6 months. Conclusion: Our study demonstrated a high prevalence of anxiety symptoms within a cohort of 92 females with TS. In alignment with current guidelines, these findings indicate the importance of routine neuropsychological assessments for timely recognition and subsequent management of anxiety, especially as milder presentations may otherwise go unnoticed. We have shown that screening tools, such as the PROMIS® Anxiety measure, can be easily utilized by nonmental health care providers (i.e., endocrinologists) who may see TS patients more frequently and be able to initiate impactful discussions surrounding mental health and further referral to subspecialists for expert management.

Rise of teledermatology in the COVID-19 era: A pan-world perspective.

ObjectiveDuring the coronavirus disease pandemic, enforced restrictions prevented face-to-face consultations for patients requiring non-emergency medical treatment. In response, there was a rise in telemedical practices, such as teledermatology. This study aimed at understanding the pan-world experiences of patients and healthcare staff who adapted to teledermatology in the coronavirus disease era.MethodsThis study made use of an online survey presented to dermatology professionals using social media and WhatsApp groups. Professionals who applied teledermatology between March and June 2020 were targeted. The survey was designed to identify respondent demographics and the preferred platforms for digital consultations. The most common diagnoses and rates of referral for further evaluation were recorded. Lastly, a platform was provided for practitioners to report their own and their patient's perspectives on the advantages and operational challenges of teledermatology. Data were collated and analyzed in Microsoft Excel.ResultsIn total, 653 stakeholders participated, representing countries worldwide. Facebook and WhatsApp services were the most popular mediums of digital consultation. Diagnoses of ailments, such as acne and eczema, as well as skin-related infections, were most common. Of the cases referred for biopsy, 10 patients were subsequently diagnosed with cutaneous malignancies. Practitioners and patients not only reported personal benefit from adopting teledermatology, but also reported concerns regarding data privacy and the levels of technological literacy required.ConclusionsTeledermatology proved an innovative clinical response to unprecedented challenges. However, further policy development and technological advancement aimed at increasing the diagnostic power of digital consultations are needed to support the continuation of teledermatology in the post-pandemic world.

Referral rate for obstructive sleep apnea in a pre-doctoral dental clinic using the STOP-Bang Questionnaire.

Obstructive sleep apnea (OSA) is a common condition that can result in significant illness when untreated. Only 10%-20% of individuals with OSA are believed to be properly diagnosed. Consequently, dentists are encouraged to identify patients at high risk for OSA. The aim of this study was to determine whether patients in a dental school student clinic were referred for evaluation of OSA when appropriate. All patients 18 or older admitted to the College of Dentistry between July 2017 and March 2020 completed a medical history form. Data were extracted from their responses to determine a STOP-Bang score, as well as data regarding a previous diagnosis of OSA and a list of referrals. Students are expected to refer patients appropriately where there are indications of a high risk of undiagnosed disease. In the case of a sleep apnea evaluation, this would include any patient whose STOP-Bang score was 5 or greater, per the lecture on sleep disorders. For patients identified as high risk, notes and referral forms were reviewed to determine if the appropriate referral occurred. Of the 21,312 new patients, 1098 (5.2%) were identified as high-risk for OSA. Of those, 398 (36%) had not been previously diagnosed with OSA. None of these 398 patients received a referral for further evaluation of OSA. The rate of referral for further evaluation for patients deemed at high risk for OSA was inadequate. Continued education and changes to the electronic health record are needed to ensure those at high-risk for OSA are appropriately managed.

Abstract 24: Compliance with Referral for Evaluation of Breast Abnormalities among HIV-Clinic Patients in Eswatini

Abstract Purpose: Women living with HIV (WLHIV) are living longer and are at increasing risk for breast cancer (BC). Earlier detection of BC is essential to reduce late-stage diagnosis and BC mortality in sub-Saharan Africa, the region most heavily impacted by HIV. We implemented a pilot BC early detection program in Eswatini HIV clinics and studied patients' compliance with referral for evaluation of breast abnormalities. Methods: Nurses at five Eswatini HIV clinics were trained to ask all WLHIV aged ≥18 years about breast symptoms, to offer clinical breast exam (CBE) to symptomatic women, and to refer for further evaluation if appropriate. Referred, consenting patients completed baseline demographic questionnaires and questionnaires at 30- and 60-days post-enrollment, regarding referral outcomes. We used chi-squared testing to identify patient characteristics associated with completing referral. Results: From June 2019-April 2020, 9,502 WLHIV were screened for breast symptoms: 150 (1.6%) underwent CBE; 93 (62.0%) of those were referred for further evaluation; and 90 (96.7%) were enrolled in the evaluation. Of enrolled WLHIV, median age was 39 (range: 20-65) years, 54 (61.0%) reported completing referral. Referral completion was not associated with age, employment status, relationship status, or various prior experiences related to BC (all p>0.05). Of those who completed referral, 42 (80.7%) reported having no illness identified, 3 (5.8%) reported a new BC diagnosis, 1 (1.9%) reported a breast abscess, and 6 (11.5%) were still undergoing evaluation; diagnosis was missing for 2. The most common reasons cited for not completing referral were cost of transport or care, conflicting employment-related commitments, other conflicting commitments, and the breast clinic not accommodating the patient upon presentation. Conclusion: In this pilot BC screening program, 60% of WLHIV completed referral for further evaluation. Efforts to improve compliance with referral could focus on reducing the time and cost entailed by obtaining specialized breast care. Citation Format: Daniel O'Neil, Sifiso Nxumalo, Cebisile Ngcamphalala, G Tharp, Judith Jacobson, Harriet Nuwagaba-Biribonwoha, Xolisile Dlamini, Alfred Neugut, Tiffany Harris. Compliance with Referral for Evaluation of Breast Abnormalities among HIV-Clinic Patients in Eswatini [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 24.

420 Evaluating the Rate of Referral for Obstructive Sleep Apnea in a Pre-Doctoral Dental Clinic Using the STOP-Bang Questionnaire

Abstract Introduction The STOP-Bang Questionnaire is a validated instrument to assess an individual’s risk for obstructive sleep apnea (OSA). The prevalence of OSA is estimated at 20% in the US with only 20% of those individuals properly diagnosed. Dentists are being asked to screen and refer patients at high risk for OSA for definitive diagnosis and treatment. The aim of this study was to determine whether patients in a dental school student clinic who were identified as high-risk for OSA, were referred for evaluation of OSA. Methods All new patients over the age of 18 admitted to The Ohio State University - College of Dentistry complete an “Adult Medical History Form”. Included in this study were 21,312 patients admitted between July 2017 and March 2020. Data were extracted from the history form to determine the STOP-Bang Score for all patients: age, sex, BMI, self-reported snoring-, stopped breathing/choking/gasping while sleeping-, high blood pressure-, neck size over 17” (males) or 16” (females)-, and tiredness. Each positive response is a point, for a maximum of 8 points possible. Additionally, any previous diagnosis of sleep apnea, and the patient’s history of referrals were extracted from the health record. According to clinic policy, if the patient did not have a previous diagnosis for OSA noted in the health history, and scored 5 or more on the STOP-Bang Questionnaire, they should receive a referral for an evaluation for OSA. Notes and referral forms were reviewed to determine if the appropriate referrals occurred for patients at high risk without a previous diagnosis. Results Of the 21,312 patients screened; 1098 (5.2%) screened high-risk for OSA, of which 398 had no previous diagnosis of OSA. Of these 398 patients, none (0%) had referrals for further evaluation for OSA. Conclusion The rate of appropriate referrals from a student dental clinic with an electronic health record was unacceptably low. Continued education and changes to the electronic health record are needed to ensure those at high-risk for OSA are appropriately referred and managed. Support (if any):

Oro-facial-digital syndrome type I: a case report with novel features.

ABSTRACTOro-facial-digital syndrome is a group of rare heterogeneous hereditary disorders characterized by abnormalities of the oral cavity, face and digits, along with varying degrees of mental retardation. Currently, Oro-facial-digital syndrome has been classified into 14 types and two additional unclassified variants have been proposed. Amongst the various variants described, Oro-facial-digital syndrome type I is the most common. We report an interesting subclinical sporadic case of Oro-facial-digital syndrome type I in a 21-year-old female patient. Interestingly, our patient presented with a few novel hitherto unreported clinical findings like midline pits in the philtrum area and a hamartomatous proliferation of tissue in the anterior maxillary alveolar gingival region. This case report highlights the importance of prudent histopathological-clinical correlation, which can direct the flow of clinical investigations leading to the detection and diagnosis of unsuspected conditions as learned in this case. We would also like to emphasize that comprehensive examination of new born for structural abnormalities of the orofacial region is crucial to early diagnosis of syndromes and subsequent referral for further evaluation and management.

Early Identification of Young Children with ASD and Other Developmental Disabilities: Areas for Improvement

There continues to be an ongoing effort in pediatric practice to improve screening and referral rates of children with potential developmental disabilities including Autism Spectrum Disorder (ASD). Successes have been seen in practices relative to broad developmental screening efforts and increasing improvement in screening for ASD. However, gaps continue to occur in screening, referral for further evaluation, and follow-up that allows the practice (and treating provider) to know the outcome of the referral. This type of “closing the loop” between providers and referral sources is necessary for the practice to function as a medical home for the child and family. In addition, caregivers have highlighted many challenges in the early identification process in working with their primary care provider. This manuscript discusses some of the barriers to early identification for children and their families, successful strategies for more consistent screening and closing the loop following referral, and highlights parental perceptions about identification and referral. Further, practical approaches that could be used by pediatric providers are highlighted.

Fibroepithelial Polyp: An Unusual Cause of Acute Urinary Retention in a 5-Year-Old Boy

A 5-year-old boy with no significant history presented to the emergency department with a 3-day history of progressively worsening difficulty with urination, poor urinary stream, and urinary retention. Urinalysis at the patient's primary care provider’s office showed microscopic hematuria with proteinuria, prompting ED referral for further evaluation.

Survey of the initial management of celiac disease antibody tests by ordering physicians

BackgroundAppropriate interpretation of a positive celiac antibody test by an ordering physician is important in order to institute proper management. We evaluated why children with an initial positive celiac serology were not referred for diagnostic biopsy or followed with serial testing by the ordering physician.MethodsConsecutive celiac serologies in all patients less than 18 years of age were evaluated over 3.5 years and 775 children with a positive tissue transglutaminase antibody (TTG) were identified. If no management of a positive TTG could be identified, a survey was sent to the ordering physician. Responses were categorized as appropriate or inappropriate management.ResultsOf the 775 patients with a positive TTG, 193 (24.9%, 95% CI 21.9–28.1%) received no follow-up management. We contacted 173 ordering physicians and 120 (69%) responded. Of the 120 responses, 55 patients (45.8%, 95% CI 36.8–55.1%) were managed appropriately and 46 (38.3%, 95% CI 29.7–47.7%) were considered to be inappropriately managed when no repeat TTG was obtained within 18 months. Reasons for inappropriate management included: screen considered to be false positive (44.7%), patient was not experiencing symptoms of celiac disease (31.6%), symptoms had resolved (15.8%), results were not indicative of celiac disease (26.3%) and patients started a gluten-free diet with no evaluation of response (15.8%). In 19 patients the TTG was not acted upon for technical reasons.ConclusionsPositive TTGs require appropriate interventions. These include: subspecialist referral for further evaluation and/or repeat testing to evaluate: 1) treatment response or 2) patients with minimal or no symptoms.

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and

RECURRENT ANGIOEDEMA AS A PRESENTING SYMPTOM OF MIXED CONNECTIVE TISSUE DISEASE IN A PEDIATRIC PATIENT

Introduction Idiopathic angioedema without urticaria presents infrequently and warrants investigation for an underlying etiology. Autoimmune conditions are a rare cause of acquired angioedema (AAE). The identification of an underlying cause has significant potential implications for treatment and thus resolution of AAE. We present a patient who was diagnosed with mixed connective tissue disease (MCTD) after initially presenting with recurrent angioedema. Case Description A 17-year-old female with a six-month history of recurrent angioedema without urticaria presented for evaluation to an outpatient pediatric allergy clinic. At initial presentation, she denied musculoskeletal complaints. Laboratory evaluation revealed a significantly elevated sedimentation rate with a normal C-reactive protein. Over the next several months she developed pain and stiffness, particularly in her wrist and elbow joints. These findings triggered rheumatologic referral for further evaluation. She was ultimately diagnosed with MCTD with corresponding U1-ribonucleoprotein antibodies and high titer anti-nuclear antibodies. She was started on mycophenolate mofetil and hydroxychloroquine for MCTD treatment with resolution of her arthritis and no further episodes of angioedema. Discussion The pathophysiology of nonhistaminergic idiopathic angioedema remains unknown. This case highlights the need to asses for concurrent rheumatologic and autoimmune symptoms while evaluating AAE in the absence of urticaria, especially in the pediatric population. To our knowledge, this is the first report of MCTD presenting as acquired angioedema in published literature.

Reliability and validity of the Thinking Skills Inventory, a screening tool for cross-diagnostic skill deficits underlying youth behavioral challenges.

Deficits in a range of skill domains (including executive functioning, emotion regulation, social cognition and language/communication) are associated with disrupted youth behavior and functioning across mental health diagnoses. The identification of skill deficits are important for effective treatment planning, particularly for personalized interventions. While there are multiple ways to assess these skills, parent/caregiver reports represent an important information source. To date, no single, brief measure has been developed that gathers parent/caregiver ratings across this range of constructs. We have developed a short caregiver-report questionnaire (the Thinking Skills Inventory; TSI), to screen for skill deficits. Here, we examine the reliability and validity of this rating scale in 384 youth who were consecutively referred for neuropsychiatric evaluation. A primary caregiver completed the TSI as well as other established measures. Exploratory and confirmatory factor analyses support five subscales on the TSI: Attention and Working Memory, Language and Communication, Emotion Regulation, Cognitive Flexibility, and Social Thinking Skills. The subscales showed moderate to high internal consistency (Cronbach's alphas range from 0.84 to 0.91). Correlations with established caregiver-report measures confirm their convergent and discriminant validity, and associations with multiple clinical diagnoses and cross-diagnostic aggressive behavior further support the utility of the scale for our intended purpose. In sum, this free, brief measure is a valid and reliable way to identify variation in skill domains relevant to a range of psychopathology. The TSI may be useful in youth mental health settings to assist with treatment planning and to inform referral for further evaluation.