Referral Patterns Research Articles

EROS: Engendering reproductive health within oncologic survivorship—ECOG-ACRIN E1Q11 paradoxical provision of reproductive health.

11123 Background: For the 10% of women diagnosed with cancer in the reproductive age, reproductive health (RH) is a critical component of oncologic survivorship. RH includes oncocontraception (OC), oncofertility (OF) and sexuality. Guidelines segregate these components resulting in fragmented reproductive health care management. Methods: The EROS trial is a clustered randomized trial performed at 17 NCI Community Oncology Research Program (NCORP) sites (including 8 NCORP sites and 9 Minority/Underserved NCORP sites) from 2016-2023. Eligible subjects included reproductively capable women aged 15-55 with new cancer diagnosis. Intervention included RH didactics and decision aids. Childbearing interest was dichotomous, not completed childbearing (including either pregnant or future childbearing interest) or completed childbearing. The objective of this study is to determine provision of OC and OF referral by providers at the baseline visit based on patient’s self-reported childbearing interest at study entry. Chi-square tests were used to compare distribution differences in the referral status (receipt: yes vs. no) between treatment arms. Results: The EROS study enrolled 420 subjects. Of the 63.6% (267/420) completed childbearing, 62.4% (58/93) in the intervention arm and 40.2% (70/174) in the non-intervention arm received an OC referral (p=0.0006), whereas 98.9% (92/93) in the intervention arm and 93.7% (163/174) in the non-intervention arm received an OF referral (p=0.0487). Of the 36.4% (153/420) not completed childbearing, 48.3% (28/58) in the intervention arm and 33.72% (32/95) in the non-intervention arm received an OC referral (p=0.0729), while 77.6% (45/58) in the intervention arm and 70.5% (67/95) in the non-intervention arm received an OF referral (p=0.3388). Conclusions: While the intervention increased the rates of provision of oncocontraception and oncofertility for patients with completed childbearing, our study shows provision of oncofertility referrals at a markedly higher rate than oncontraception. Referral patterns were inconsistent with patient need particularly in completed (receiving OF referral) or delayed childbearing (not receiving OC referral) interest of the patient. The bias favoring oncofertility referral may reflect oncology guidelines emphasizing this aspect of reproductive health despite comprehensive needs of patient.

Implementation of and Systems-Level Barriers to Guideline-Driven Germline Genetic Evaluation in the Care of Patients With Myelodysplastic Syndrome and Acute Myeloid Leukemia.

Knowledge of an inherited predisposition to myelodysplastic syndrome (MDS) and AML has important clinical implications for treatment decisions, surveillance, and care of at-risk relatives. National Comprehensive Cancer Network (NCCN) guidelines recently incorporated recommendations for germline genetic evaluation of patients with MDS/AML on the basis of personal and family history features, but the practicality of implementing these recommendations has not been studied. A hereditary hematology quality improvement (QI) committee was formed to implement these guidelines in a prospective cohort of patients diagnosed with MDS/AML. Referral for germline genetic testing was recommended for patients meeting NCCN guideline criteria. Referral patterns and genetic evaluation outcomes were compared with a historical cohort of patients with MDS/AML. Barriers to evaluation were identified. Of the 90 patients with MDS/AML evaluated by the QI committee, 59 (66%) met criteria for germline evaluation. Implementation of the QI committee led to more referrals for germline evaluation in accordance with NCCN guidelines (31% v 14%, P = .03). However, the majority of those meeting criteria were never referred due to high medical acuity or being deceased or in hospice at the time of QI committee recommendations. Despite this, two (17%) of the 12 patients undergoing genetic testing were diagnosed with a hereditary myeloid malignancy syndrome. Current NCCN guidelines resulted in two thirds of patients with MDS/AML meeting criteria for germline evaluation. A hereditary hematology-focused QI committee aided initial implementation and modestly improved NCCN guideline adherence. However, the high morbidity and mortality and prolonged inpatient stays associated with MDS/AML challenged traditional outpatient genetic counseling models. Further improvements in guideline adherence require innovating new models of genetic counseling and testing for this patient population.

Assessing secular trends in lung cancer stage in the United States community oncology setting from 2013 to 2023.

11178 Background: Detecting disease at an early stage is critical to improving lung cancer (LC) survival, as reflected in guidelines recommending screening with low dose computed tomography for individuals at high risk by clinical societies including the NCCN (2011) and US Preventive Services Task Force (2013, updated 2021). Presenting stage distribution may also be impacted by healthcare utilization changes following the COVID-19 pandemic. Real-world data (RWD)-based investigations are important complements to national cancer registries to provide insight into this potentially changing diagnostic landscape, especially given utilization, practice and referral patterns unique to community settings. We thus assessed LC stage from 2013-23 in a large, nationally representative sample of community oncology practices leveraging RWD. Methods: This is a retrospective observational cohort study of patients within The US Oncology Network and non-Network practices, which include a nationally representative network of over 3,700 providers and more than 1 million patients seen annually in community-based oncology practices. All adult (≥18 years) patients diagnosed with non-small cell LC (NSCLC) or small-cell LC (SCLC) who had a first observed stage available in the community oncology setting within 2013 to 2023 were included. Demographics and medical history data were sourced from structured data fields in iKnowMed, an oncology-specific electronic health record system. Time trends of patient diagnosis and characteristics were descriptively evaluated. Results: The analysis included 98,806 patients with LC (84,023 [85.0%] NSCLC and 14,783 [15.0%] SCLC). Approximately half were female (49.7% and 50.3% in each disease), three-fourths were White (72.7% and 77.0%, respectively), and mean ages at diagnosis were 69.9 and 68.1 years. From 2013 to 2023, there was an increase in the total number of patients observed in the database with a documented stage, from 7,159 to 9,115 (27.3% increase) for NSCLC and from 1,162 to 1,595 (37.3% increase) for SCLC. This was largely driven by an absolute increase in advanced stage diagnoses. The proportion of patients diagnosed with Stage IV NSCLC increased from 43.3% in 2013 to 49.3% in 2023, while the proportions of Stage 0/I and II diagnoses decreased. A similar trend was observed for SCLC, with 60.3% of patients diagnosed with Stage IV in 2013 compared to 68.2% in 2023. The proportion of Stage IV NSCLC cancers increased in the pandemic period, from 48.0% in 2019 to 51.6% in 2020 and 50.6% in 2021. Conclusions: Over the last decade, the proportion of advanced stage LC cases has increased, possibly reflecting changes in referral patterns and utilization specific to the community setting, including those related to the COVID-19 pandemic. The burden of advanced disease highlights the need for continuous investment in advanced-stage treatments as well as early detection efforts.

Establishing palliative care in tribal and rural Indian setting: A participatory action research approach.

e24085 Background: We established a palliative care center in the tribal area of Santhal Pargana, India, under a tertiary care facility, as a crucial step in addressing the palliative needs of oncology patients. This study assesses the center's inaugural year, focusing on referral patterns, morphine consumption, and pain management. Methods: Data from all patients visiting the palliative care outpatient department (OPD) in 2023 were prospectively collected and analyzed. The study focused on key palliative care indicators, including morphine consumption, patient referrals, and the mean Numeric Rating Scale (NRS) pain score after initial consultation. The PAR approach was utilized to tailor services to the community's needs. Results: The center observed an increase in patient referrals, from 8 new patients in January to 19 by December. The patient demographic primarily comprised individuals with head and neck cancer (43%), followed by breast cancer (28%) and gall bladder cancer (12%), alongside other types such as cervix, sarcomas, lung, and adult hematolymphoid malignancies. Bone metastasis was present in 46 (55.4%) patients at initial presentation. Morphine consumption demonstrated a notable rise, from 840 mg in May to 2860 mg in December, totaling 9800 mg for the year. The mean NRS pain score improved significantly from 6.5 in January to 4.3 post-initial consultation. The center maintained an overall median of 3 consultations per patient, and bereavement support was provided to 13 (15.7%) patients. Conclusions: The integration of the Participatory Action Research approach, specifically the CTC-5, was instrumental in the successful initiation and expansion of palliative care services within the center. The structured training, mentorship, and organizational restructuring, facilitated by the program, were crucial in establishing a modest palliative care infrastructure. This comprehensive approach not only enhanced care delivery but also ensured the sustainability and adaptability of palliative services, effectively addressing the gap in palliative care in rural, tribal settings.

Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings

ObjectivesThis study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments.Design, setting, participantsThis retrospective cohort study...

Clinicians' experiences and perspectives of a web-based lung cancer referral pathway.

e13539 Background: Efficient and streamlined referral of patients with suspected lung cancer is an integral part of providing optimal care for these patients. There is emerging evidence that use of online care pathways, such as HealthPathways is associated with improved referral quality from primary care, more timely access to secondary care and standardization of clinical management decisions by general practitioners (GPs). The Townsville Lung Cancer Referral Pathway (TLCRP) is part of ' Townsville HealthPathways', which is the evidence-based clinical pathway portal used in the Townsville Hospital and Health service in northern Australia. This study aimed to explore the experiences and perspectives of clinicians about TLCRP. Methods: This was a descriptive qualitative study nested within a larger project evaluating TLCRP, utilising a broader implementation science framework. In-depth, semi-structured interviews of GPs and lung cancer specialists were conducted. An iterative, inductive thematic analysis of interview transcripts was undertaken to derive key codes and themes regarding participant experiences and perceptions. Results: Twenty interviews were conducted, 14 with GPs and six with specialists across disciplines of respiratory medicine, oncology, and cardiothoracic surgery. Of the GPs, 11 were practicing in the regional locality of Townsville and three practiced in surrounding rural areas. Interview analysis identified two major themes and several sub-themes (Table). Several enablers and barriers to implementing TLCRP were identified. Barriers to adaptation of TLCRP included lack of clinical time, resistance to changing referral patterns, lack of familiarity or experience with HealthPathways and technology issues. Enablers included clinical usefulness of TLCRP, support from HealthPathways implementing team, integration of TLCRP with the electronic referral system and positive feedback from specialists. Conclusions: Emerging themes from this study may be used to reduce the barriers and improve uptake of TLCRP and other health care pathways in the local health service. Improving the uptake of TLCRP may mean that more patients in our region experience a streamlined journey to more timely specialist lung cancer care and improved health outcomes. [Table: see text]

Timing of genetic testing referral and genetic testing results in patients with multiple primary cancers.

10592 Background: An individual diagnosed with a metachronous or synchronous cancer that arises independently, not due to recurrence or metastasis, has multiple primary cancers (MPC). Practice guidelines recommend germline genetic testing based on specific combinations of primary cancers and ages of diagnoses but do not recommend testing for all patients with MPC. In prior work (PubMed ID 37276540), we found that patients with breast cancer are more likely to receive testing than patients with other primary cancer types. Here, we evaluated whether a first breast cancer was more likely than another first cancer type to prompt testing referral. Methods: Using Oncoshare, a breast cancer research database that integrates data from electronic medical records and the California Cancer Registry, we identified female patients with MPC diagnosed between January 2000 and June 2023 with breast cancer as either the first or second cancer and seen at Stanford University. We analyzed testing rates after first vs. second cancer diagnosis and the yield of pathogenic variants (PV). We evaluated the association between the receipt of genetic testing and the timing of breast cancer (1st or 2nd), using both univariate and multivariable logistic regression that adjusted for age at first diagnosis, race/ethnicity, and time between the first and second diagnoses. Results: 1,069 patients met the study eligibility; 75% were non-Hispanic White, and 73% had breast as the first cancer. 342 (32%) patients had testing, and 113 (33%) had at least one PV. Most patients had testing after the first cancer (44%, n=150) or after the second cancer (48%, n=165) (Table). Those with breast cancer as their first primary tended to have a higher testing rate, (OR 1.62, 95% CI 0.9-3.0), however, the statistical significance of this association was attenuated in the multivariable model with more parameters (P=0.11), possibly due to small sample size. Overall PV yield (33%) was high, consistent with a tertiary referral center. Conclusions: In this academic clinic-based sample of patients with MPC, we observed a higher testing rate when breast vs. another cancer was the first primary although it did not reach statistical significance. Additional research is needed to validate this finding in a larger cohort and determine whether similar referral patterns are observed in community practice, where most U.S. patients receive cancer care. [Table: see text]

Navigating the clinical trial maze: Identifying barriers to enrollment among patients with advanced cancer in a community-academic partnership.

e15191 Background: Further research is required to pinpoint barriers responsible for disparities in clinical trial enrollment. In Alabama, a community-academic partnership has been established to broaden clinical trial access and eliminate disparities. This study aims to examine referral patterns for phase 1 and precision oncology clinical trials and identify screening and enrollment barriers. Methods: Between July-December 2023, we conducted weekly virtual meetings for patients (n=115) seen at Infirmary Health Oncology clinic (Mobile, AL) [community site] who had Next Generation Sequencing data and were potentially eligible for a clinical trial. We recorded key sociodemographic variables, retrospectively analyzed genomic data, examined trial enrollment, and explored non-participation reasons. Descriptive statistics were employed for analysis. Results: A total of 115 patients were included in this retrospective study. The median age was 70 years (range: 38-90), 60% were male vs. 40% female, and the majority were Caucasian (63%). The most common tumor types were: non-small cell lung cancer (27.8%), colorectal cancer (13.0%), pancreatic cancer (11.3%), small cell lung cancer (10.4%), and breast cancer (6.9%). We found that genomic alterations commonly included: TP53 (34.7%), KRAS (20%), PTEN (13.9%), NF (11.3%), CDK (7.8%), and PIK3CA (6.1%). Of the patients prescreened, 11.3% did not return to clinic for subsequent follow up visits and 16.5% did not have an available trial. 33% were pre-screened for clinical trial but did not meet trial eligibility criteria because of cancer stage, number of prior therapies therapy, or some other exclusion criteria. Among these, 18.4% were not eligible due to HIV or immunosuppressed status, a second malignancies, brain metastasis or poor performance status. 45 of the 115 patients (39.1%) had a clinical trial available at UAB. However, 26 (57.7%) of these patients were ultimately unable to participate due to: technical factors (n=10, 38.5%) [biopsy not obtainable/QNS/repeat biopsy needed], patient preference (n=9, 34.6%) and physician preference (n=7, 26.9%). Of the 19 (42.22%) remaining patients who were potentially eligible, only 3 (15.8%) patients were eventually enrolled on a clinical trial. All 3 patients went onto disease specific phase 2-3 trials, rather than a precision medicine or phase 1 trial. Conclusions: Our study highlights key factors affecting referrals, screening, and barriers to clinical trial enrollment. Early referrals and improved screening processes are crucial for considering trials, with prior therapy lines and functional status playing significant roles in trial non-enrollment. Our community-academic partnership aims to overcome barriers like travel and trial access, while also leveraging technology (eg. AI and databases) to address technical obstacles in trial participation.

Iliotibial Band Origin Tendinopathy Is an Underrecognized Cause of Anterolateral Hip Pain: A Narrative Review and Clinical Commentary.

Hip pain is a common concern among athletes. With gluteal tendinopathy, femoroacetabular impingement, and osteoarthritis predominating sports medicine and musculoskeletal practices, less common etiologies may be overlooked. Complex pelvic anatomy and variable pain referral patterns may make identifying an accurate diagnosis challenging. Employing a systematic approach to evaluation and having a thorough understanding of hip region anatomy are essential. A potentially overlooked cause of anterolateral hip pain is iliotibial band origin tendinopathy. Patients often present with pain around the anterolateral hip and tenderness to palpation at the anterolateral iliac crest. While patients with iliotibial band origin tendinopathy usually respond to nonsurgical intervention, there is little literature to guide evaluation and treatment, highlighting a gap in the recognition of this condition. The purpose of this narrative review is to describe the anatomy of the proximal iliotibial band origin, outline the clinical diagnosis and imaging findings of ITBOT, and summarize current treatment options.

Oncologic outpatient specialty palliative care referral utilization: A single institution quality improvement project.

e23205 Background: ASCO recommends that late-stage and/or recurrent disease patients with a prognosis of 6-24 months receive specialty palliative care within eight weeks of diagnosis. Prior studies suggest only 30% of eligible patients are referred to outpatient palliative care. Little is known about existing referral patterns to direct quality improvement initiatives. Our aim was to characterize outpatient palliative care referral sources, timeliness, and completion rates across our cancer center. More broadly, this investigation may serve as a model for outpatient palliative care utilization improvement at other cancer centers. Methods: A single institution retrospective quality improvement study was conducted of patients in the seven oncology subspecialties with the most palliative care referrals from 2019 – 2022. Data collected included demographics, referral source, and utilization metrics. Outcomes were rate of referral completion and time from referral to first palliative care visit, hospice enrollment, and/or death. Descriptive statistics were performed. Results: 1671 outpatient specialty palliative care referrals were placed. 57% were initiated by medical oncologists, 21% by inpatient palliative care consulting service at hospital discharge, and 14% by surgical oncology. 27% of referred patients did not schedule an appointment. Gynecologic and breast cancer patients had the highest rates of being scheduled. Median time from referral to appointment was 20 days (interquartile range 9 – 30 days). Reasons patients did not utilize palliative care included transition to hospice (41%), lack of interest (41%), or death prior to visit (7%). 79% of patients seen by palliative care who died were enrolled in hospice. Median time from palliative care referral to hospice enrollment was 66 days (IQR 22 – 164 days), and median time from hospice enrollment to death was 13 days (IQR 5 – 31 days). Conclusions: In a single institution self-evaluation, most patients referred to outpatient specialty palliative care completed referral within thirty days. Within the context of this institution, relevant goals for quality improvement interventions include increasing palliative care referrals among surgical oncologists and shifting palliative care referrals earlier in the disease course and prior to need for inpatient hospital admission. Understanding the elements of the creation of our palliative care referral database and relevant data tracking may serve as a method for other institutions to target interventions that may improve uptake of outpatient palliative care referrals at cancer centers more broadly.

Prevalence of Obesity-Related Disease in a Danish Population - The Results of an Algorithm-Based Screening Program.

The prevalence of obesity continues to rise. People with obesity are at increased risk of several diseases. We tested an algorithm-based screening program for people with a BMI above 30 kg/m2 and present data on the prevalence of previously undiagnosed obesity-related diseases. Seven hundred and sixty-nine persons with BMI > 30 kg/m2 and age 18-60 years were screened for diabetes (assessed by glycosylated hemoglobin and oral glucose tolerance test at HbA1c 43-48 mmol/mol), sleep apnea (screened by questionnaires and assessed by cardiorespiratory monitoring at indication of sleep disorder), liver steatosis or liver fibrosis (assessed by biochemistry and fibroscan) and arterial hypertension (assessed by both office and 24-hour blood pressure measurement). A reference group of people with a BMI of 18.5-29.9 kg/m2 was established. Of those referred, 73.0% were women. We identified new diabetes in 4.2%, prediabetes in 9.1%, moderate-to-severe sleep apnea in 25.1%, increased liver fat and increased liver stiffness in 68.1% and 17.4%, respectively, and hypertension or masked hypertension in 19.0%. The prevalence of diseases was much higher among men and increased with BMI. Except for hypertension, we found few participants with undiagnosed disease in the reference group. An algorithm-based screening program is feasible and reveals undiagnosed obesity-related disease in a large proportion of the participants. The disproportional referral pattern calls for a tailored approach aiming to include more men with obesity. Inclusion of the non-obese group was approved by the Scientific Ethics Committee of The Region of Southern Denmark (project identification number: S-20210091), and the study was reported at clinicaltrials.gov (NCT05176132).

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

BackgroundPresentation to the emergency department (ED) with self-harm provides an important opportunity for intervention.AimsTo investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health–related aftercare.MethodData on consecutive self-harm presentations to EDs for the years 2013–2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated.ResultsHalf of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health–related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51–0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017–2019 vs. 2013–2016), but was more likely for those brought by ambulance, presenting outside 9 am–5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14–10.62).ConclusionsThe findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Etiology and Management of 800 Patients With Facial Palsy at a Private Practice Setting Over a 5-Year Period.

Very few papers investigated the etiologic breakdown and demographic characteristics of patients with facial nerve (FN) palsy. Our paper aims to present the etiologic breakdown and demographic characteristics of patients with FN palsy, presenting at a private care center between 2014 and 2019, along with the treatment modalities that were offered to them. Charts of 800 patients with facial palsy (FP) were reviewed. Data included the etiology of their diagnosis, family history, recurrent FP, demographic information, and treatment provided before and after presentation. Seventy-five percent of our study population were females. The average period between diagnosis with FP and presentation at our center was 10.8 years. The most commonly identified etiology was Bell's palsy, followed by acoustic neuroma. Eighty-one percent of the study subjects were prescribed steroids and/or antivirals. Facial neuromuscular retraining, electrical stimulation, chemodenervation, and surgical intervention were also part of some treatment plans for our population. Recommendations for the treatment of idiopathic FP include steroids with adjuvant antiviral medications. Data remains uncertain whether the combination therapy of steroids and antivirals has better results compared to steroids alone. Electrical stimulation is still a controversial therapeutic tool for facial paralysis with a potential role in exacerbating synkinesis. The difference in referral patterns between tertiary and private care centers can explain the disparity in the ranking of the etiologies between our study and what has been published. Management of FP is a complex process. The FN community must develop a common database to improve its understanding of the different presentations.

Incidence and Management of Cardiothoracic Relevant Extrapulmonary Findings Found on Low-Dose Computed Tomography

BackgroundWe aimed to investigate the incidence of extrapulmonary findings identified on low-dose computed tomography (CT) that may warrant evaluation by cardiothoracic surgeons and describe their management and referral patterns at our institution. MethodsWe conducted a retrospective cohort study of patients who underwent low-dose CT through a centralized Lung Cancer Screening Program at Thomas Jefferson University Hospital between January 2018 and December 2022. An electronic medical record review was performed for patients with incidental findings. Demographic, workup, referral, and management data were collected. ResultsOf 2285 patients who underwent low-dose CT, 368 (16%) had an extrapulmonary finding that may have an indication for clinical evaluation by a cardiothoracic surgeon. The most common incidental finding was a hiatal hernia, with a prevalence of 6.3% (144 of 2285), followed by ascending thoracic aneurysms, with a prevalence of 3.6% (82 of 2285), and small pericardial effusions, with a prevalence of 1.2% (28 of 2285). Of the patients with symptomatic hiatal hernias, 29% (14 of 48) were referred to a cardiothoracic surgeon compared with only 6.25% (6 of 96) in the asymptomatic group. Of the patients with thoracic aneurysms, 48% (39 of 82) had aneurysms ≥4.2 cm. Of the ≥4.2 cm group, 18% (7 of 39) were monitored by a cardiothoracic surgeon compared with 11.6% (5 of 43) in patients with aneurysms <4.2 cm. ConclusionsHiatal hernias and ascending thoracic aneurysms were the 2 most prevalent incidental findings identified on low-dose CT during lung cancer screening. We demonstrated potential gaps in hiatal hernia referral patterns. Referring patients with thoracic aneurysms to cardiothoracic surgeons may not be initially warranted.

Application of the Symptoms-Varices-Pathophysiology classification system in patients with pelvic venous disorders.

Introduction: In 2021, the American Vein and Lymphatic Society convened a multi-disciplinary group to develop a valid and reliable discriminative instrument for the classification of patients suffering from pelvic venous disorders (PeVD) referred to as the Symptoms-Varices-Pathophysiology (SVP) system. Limited data exists regarding the utility of this instrument in the care of patients with PeVD. The goal of this investigation is to apply the SVP classification system to a group of patients treated for PeVDs. Methods: From January 2018 to January 2019, we retrospectively reviewed the records of 70 female patients treated for a PeVD at the Center for Vascular Medicine. Age, race, gender, medical/surgical histories, CEAP classification and intervention types were assessed and patients were categorized according to their SVP classification. The prevalence of each S and V class, their association with gonadal or iliac vein obstructive lesions and the prevalence of lower extremity varicosities was evaluated. Results: The average age of the entire cohort was 47.4 ± 13.4. The race distribution was as follows: African American (6), Hispanic (1), and Caucasian (63). Of the 140 limbs, 57% were C3 or greater with an average rVCSS score of 4.53. At the time of intervention, 54 patients (77%) demonstrated CEAP class 2 disease or greater with 25 patients (35%) demonstrating lower extremity varicosities. Medical co-morbidities included the following: Endometriosis (n = 1), Uterine Fibroids (n = 1), Ovarian cysts (n = 4), history of venous thrombosis (n = 2) and prior lower extremity venous procedures (n = 3). Overall, 47 patients (67.1%) demonstrated S2 disease secondary to dyspareunia, post-coital pain, or dysmenorrhea. S2 alone was observed in 17 patients (24.3%), S2,3a and S2,3a,3b in nine patients each (12.9%), and S2,3b was in 12 patients (17.1%). Thirteen patients presented with isolated extra-pelvic symptoms (19%); four (5.7%) were classified as S3a,3b, and nine (12.9%) were classified as S3b only. Finally, 10 patients (14%) had no pelvic symptoms and thus were classified as S0. V0 disease was observed in 17 patients (24.3%) secondary to a high incidence of iliac vein stenoses (IVS). V1 disease was observed in 1 patient (1.43%). V2 disease was observed in 53 patients (74.3%) secondary to iliac or ovarian vein reflux. Of these, 45 patients (64.3%) presented with reflux in the iliac veins. Sixteen patients had reflux in the common iliac veins, 17 patients exhibited reflux of the external iliac veins, and 41 patients demonstrated reflux of the internal iliac veins. Thirty-two patients (45.7%) presented with V2 disease secondary to reflux of the ovarian veins, 8 of whom presented with isolated ovarian vein reflux without IVS. Bilateral ovarian vein reflux was observed in 6 patients (9%) and unilaterally in 26 (37%) patients with concomitant ovarian vein reflux and IVS observed in 31 patients (44%). In patients with ovarian vein reflux, 89% had a concomitant iliac vein stenosis: (96.9% in the common iliac vein, 81.3% in the external iliac vein and 3.1% in the internal iliac vein). Conclusion: In our patient cohort, 70 women demonstrated 14 different SV classifications. The most common was S2V2, found in 10 patients. Chronic pelvic pain of venous origin, S2 disease, was the most common symptom, present in 47 patients (67.1%); followed by extra-pelvic symptoms as 22 patients demonstrated symptoms of the external genitalia (S3a), and 21 patients had symptoms secondary to the non-saphenous leg veins (S3b). Pelvic varicosities, V2, were also the most common variceal pattern seen in 53 patients, and 17 patients did not have any varices noted by venogram. Non-thrombotic IVS either alone or with ovarian vein reflux was the most common cause of PeVD in this cohort and may reflect referral patterns to our center. To determine the true incidence of these SVP patterns, larger cohort studies are necessary.

Nationwide Real-World Data of Microsatellite Instability and/or Mismatch Repair Deficiency in Cancer: Prevalence and Testing Patterns.

Determination of microsatellite instability (MSI)/mismatch repair (MMR) status in cancer has several clinical implications. Our aim was to integrate MSI/MMR status from patients tested in Greece to assess the prevalence of MSI-high (MSI-H)/deficient MMR (dMMR) per tumor type, testing patterns over time and concordance between MSI and MMR status. We retrospectively recorded MSI/MMR testing data of patients with diverse tumor types performed in pathology and molecular diagnostics laboratories across Greece. Overall, 18 of 22 pathology and/or molecular diagnostics laboratories accepted our invitation to participate. In the 18 laboratories located across the country, 7916 tumor samples were evaluated for MSI/MMR status. MSI/MMR testing significantly increased in patients with colorectal cancer (CRC) and other tumor types overtime (p < 0.05). The highest prevalence was reported in endometrial cancer (47 of 225 patients, 20.9%). MSI-H/dMMR was observed in most tumor types, even in low proportions. Among 904 tumors assessed both for MSI and MMR status, 21 had discordant results (overall discordance rate, 2.3%). We reported MSI-H/dMMR prevalence rates in patients with diverse cancers, while demonstrating increasing referral patterns from medical oncologists in the country overtime. The anticipated high rate of concordance between MSI and MMR status in paired analysis was confirmed.

Referral Patterns to Speech and Language Therapy in the UK before, during, and after the COVID-19 Pandemic: Dysphagia Compared with Communication Disorders

Introduction: Acquired swallowing impairment is a major public health issue that often leads to increased morbidity and slower recovery. Speech and language therapists (SLTs) have taken the lead in the assessment and treatment of dysphagia, which is reflected in guidelines where early intervention is recommended. This is in addition to the central role that SLTs play in the management of acquired communication impairments since research indicates that patients with communication difficulties benefit from early and intensive therapy by SLTs. This increasing demand for SLTs is expected to cause conflicting pressures in their workload and, therefore, beneficial to consider workforce planning. The aim of this study was to examine real-world data in the UK to investigate this issue regarding changes in referral patterns of patients with dysphagia and/or communication disorders to SLTs over time, to assist with workforce planning. Methods: We interrogated the Royal College of Speech and Language Therapists Online Outcome Tool, a national database, in this retrospective cohort study. We included patients evaluated between 2018 and 2022. We performed a subgroup analysis of patients aged ≥40 years who had a primary medical diagnosis of stroke. Data on age, primary diagnosis, time on caseload, primary Therapeutic Outcome Measure (TOM) scale and initial TOM score on impairment were examined. Results: From the database of 44,444 referrals to speech and language therapy, 5,254 referrals were included in the stroke and overall subgroup analyses. Referrals were 55.1% male, with a median age of 71 years. More than half (56.1%) of these referrals were for dysphagia. Referrals decreased during the COVID-19 pandemic but began to recover from 2021 onwards. The time on the SLT caseload has increased over the years from a median of 14 days (interquartile range [IQR] 0–56) in 2018 to 20 days (IQR: 3–81) in 2022. While there were more referrals to SLT services for assessment and management of dysphagia than for communication in the overall population, in the stroke subgroup, referrals for communication disorders outnumbered referrals for dysphagia from 2020 onwards. Additionally, the severity of impairment on referral increased over the years. Conclusion: Real-world data indicates that referrals to SLT services are changing over time to include more complex and severely impaired patients, with a demand for both swallowing and communication disorders. These findings should inform staff allocation and remodelling of education/training for SLTs to better meet clinical and public health needs. The retrospective nature of this study limits the strength and generalisability of these data, and this topic warrants further investigation.

Analysis of trends in radiofrequency ablation in a tertiary care center practice.

Radiofrequency ablation (RFA) for thyroid nodules has recently been introduced into the United States healthcare system landscape. Little is known about the process of incorporating this procedure into existing clinical practice. A retrospective chart review of a single institution was conducted to examine referral patterns and decision-making after the introduction of RFA into an endocrine surgery-focused practice. Patient demographics and thyroid-specific data were recorded. Two reviewers abstracted and coded reasons for the noncompletion of RFA. Two-sample t tests were used to compare groups; linear regression was used to assess trends and practice patterns. Chart review identified 451 patients referred for consideration of RFA from January 2020 to December 2022. Only 255 (56.5%) went on to receive the treatment. There was no significant difference in nodule volume between treated and nontreated groups (18.5 vs. 14.9 cm3, p = 0.07). Concern for malignancy on genetic testing, size (too large/too small), recommendation for Ethanol ablation, and multinodular disease without target nodules were the most common reasons for physician deferral. Of patients who declined to proceed, 46% opted to undergo surgical excision. Linear regression showed that referral numbers significantly increased with time; however, the proportion of patients receiving treatment decreased yearly, primarily because of higher rates of physician deferral. This study reflects the complex decision-making in offering minimally invasive thyroid nodule ablation. Despite a greater number of referrals over time, physician criteria became increasingly selective. Optimal candidacy in RFA is an evolving determination requiring patient and physician input to guide ideal practice patterns.

Assessing the factors that influence the utilization and delivery of rehabilitation services among persons with Parkinson's disease: A scoping review.

Rehabilitation has the potential to significantly improve the lives of people and, most importantly, for persons with Parkinson's disease (PD). Although numerous studies have reported the benefits of rehabilitation for persons with PD (PwPD), these services are still limited and underutilized even when patients exhibit problems that require rehabilitation. This review aims to describe the (a) indication for referral for rehabilitation services, (b) patterns of referral for rehabilitation and (c) factors that facilitate or hinder the utilization and delivery of rehabilitation services among PwPD. A comprehensive literature search was conducted across selected databases, African Journals Online, EBSCOhost (CINAHL, Africa-wide), PubMed, SCOPUS and Web of Science. Studies published in English from January 2002 until December 2022 were applied as limiters. Reference and grey data sources tracking were also conducted. Two reviewers conducted the study selection, screening of titles, abstracts and full text and data charting. A descriptive analysis was performed. Findings were narratively presented and illustrated with tables, diagrams and descriptive formats as appropriate. Twelve studies were included in the review; however, none were from Africa. Impairments and activity limitations were the key functioning problems indicated for rehabilitation. Age, gender, income, race, disease stage, specific functioning problems, quality of life and care by a neurologist were the main predictors for referral to rehabilitation. Physiotherapy, occupational therapy and speech and language therapy were the most utilized rehabilitation services and were sometimes utilized together. The rate of rehabilitation service utilization among PwPD ranged from 0.9% to 62.5%. Lack of referrals and limited rehabilitation units/professionals were the common barriers to rehabilitation service utilization. Per the studies reviewed, utilization of rehabilitation services is generally low among PwPD. Lack of referral and nonavailability of professionals are cited as barriers to access. Adequate measures are needed to improve rehabilitation services for all PwPD.

Prospective phase II trial of preoperative hypofractionated proton therapy for extremity and truncal soft tissue sarcoma: the PRONTO study rationale and design

BackgroundOncologic surgical resection is the standard of care for extremity and truncal soft tissue sarcoma (STS), often accompanied by the addition of pre- or postoperative radiation therapy (RT). Preoperative RT may decrease the risk of joint stiffness and fibrosis at the cost of higher rates of wound complications. Hypofractionated, preoperative RT has been shown to provide acceptable outcomes in prospective trials. Proton beam therapy (PBT) provides the means to decrease dose to surrounding organs at risk, such as the skin, bone, soft tissues, and adjacent joint(s), and has not yet been studied in patients with extremity and truncal sarcoma.MethodsOur study titled “PROspective phase II trial of preoperative hypofractionated protoN therapy for extremity and Truncal soft tissue sarcOma (PRONTO)” is a non-randomized, prospective phase II trial evaluating the safety and efficacy of preoperative, hypofractionated PBT for patients with STS of the extremity and trunk planned for surgical resection. Adult patients with Eastern Cooperative Group Performance Status ≤ 2 with resectable extremity and truncal STS will be included, with the aim to accrue 40 patients. Treatment will consist of 30 Gy radiobiological equivalent of PBT in 5 fractions delivered every other day, followed by surgical resection 2–12 weeks later. The primary outcome is rate of major wound complications as defined according to the National Cancer Institute of Canada Sarcoma2 (NCIC-SR2) Multicenter Trial. Secondary objectives include rate of late grade ≥ 2 toxicity, local recurrence-free survival and distant metastasis-free survival at 1- and 2-years, functional outcomes, quality of life, and pathologic response.DiscussionPRONTO represents the first trial evaluating the use of hypofractionated PBT for STS. We aim to prove the safety and efficacy of this approach and to compare our results to historical outcomes established by previous trials. Given the low number of proton centers and limited availability, the short course of PBT may provide the opportunity to treat patients who would otherwise be limited when treating with daily RT over several weeks. We hope that this trial will lead to increased referral patterns, offer benefits towards patient convenience and clinic workflow efficiency, and provide evidence supporting the use of PBT in this setting.Trial registration: NCT05917301 (registered 23/6/2023).