Referral Protocols Research Articles

Multiparametric Magnetic-Resonance to Confirm Eligibility to an Active Surveillance Program for Low-Risk Prostate Cancer: Intermediate Time Results of a Third Referral High Volume Centre Active Surveillance Protocol

Background: To evaluate the role of confirmatory multiparametric magnetic resonance imaging (mpMRI) of the prostate at the time of Active Surveillance (AS) enrollment to reduce disease misclassification. Materials: From 2012 to 2016, 383 patients with low-risk disease respecting Prostate Cancer Research International AS criteria underwent confirmatory 1.5-T mpMRI. AS was proposed to patients with Prostate Imaging and Report and Data System (PI-RADS) score ≤3 and no extraprostatic extension (EPE), whereas patients with PI-RADS score ≥4 and/or EPE were treated actively. Kaplan-Meier analyses quantified progression-free survival (PFS) in patients enrolled in the AS program. Logistic regression analyses tested the association between confirmatory mpMRI and clinically significant prostate cancer (csPCa) at radical prostatectomy (RP). Diagnostic performance of mpMRI was calculated in patients submitted to immediate RP. Results: PFS rate was 99, 90 and 86% at 1, 2 and 3 years respectively. At multivariable analysis, PI-RADS 3, PI-RADS 4, PI-RADS 5 and EPE increased the probability of having csPCa at immediate RP (PI-RADS 3 [OR] 1.2, p = 0.26; PI-RADS 4 [OR] 5.1, p = 0.02; PI-RADS 5 [OR] 6.7; p = 0.009; EPE [OR] 11.8, p < 0.001). Confirmatory mpMRI showed sensibility, specificity, positive predictive value and negative predictive value of 85, 55, 68 and 76% respectively. Conclusions: MpMRI at the time of AS enrollment reduces the misclassification rate of csPCa. We suggest to perform target biopsies in patients with PI-RADS score 3 and 4 lesions.

Integration of clinical pharmacy services into the Brazilian health system using Problematization with Maguerez Arc.

Clinical pharmacy services (CPS) have been evolving worldwide. However, it is estimated that CPS are not yet integrated into the Brazilian healthcare system. Thus, the objective of this study is to identify factors that influence the integration of CPS into the healthcare system and propose strategies for this integration. A methodological development study was conducted from August 2016 to September 2017. Thus, interviews were conducted with key informants to identify barriers, facilitators, and strategies for CPS integration. Then these collected data were organized and confronted with the literature. Finally, a nominal group defined strategies for the integration of CPS into the Brazilian healthcare system. Interviews were conducted with five managers and seven decision-makers who listed 19 barriers and 20 facilitators. From these results, the nominal group proposed 41 integration strategies and prioritized five: formalize CPS; agree on care flows and referral protocols; evaluate and publicize CPS results/benefits; plan and define CPS; sensitize the health managers CONCLUSION: This study identified factors that influence the integration of CPS into the Brazilian health system and proposed strategies to achieve this integration. These results may contribute to future health decision-making processes.

DESAFIOS DA REGULAÇÃO ASSISTENCIAL NA ORGANIZAÇÃO DO SISTEMA ÚNICO DE SAÚDE

Introdução: a regulação assistencial é um local de observação e ordenamento da rede de serviços e de gerenciamento do fluxo do usuário. Os constantes incrementos de novos procedimentos especializados devido às evoluções em ciência e tecnologias, e ao mercado de serviços em saúde requerem um planejamento dinâmico e uma gestão focada em melhorias de eficiência e eficácia. A identificação de problemas comuns às regulações pode colaborar para a prática dos gestores desta atividade. Objetivo: descrever os principais desafios enfrentados pela regulação assistencial. Materiais e Métodos: trata-se de um estudo de revisão integrativa da literatura com consulta a base SciELO scielo. Utilizou-se os assuntos “regulação de redes e sistemas de saúde”, “regulação de serviços de saúde” e “regulação em saúde” sem definição de filtros, e com a opção AND entre as palavras dos assuntos. Após leitura dos títulos fez-se um segundo filtro com leitura de resumos. Resultados: foram categorizados os seguintes desafios: 1. limitada oferta de consultas e exames na rede assistencial. 2. precariedade da referência e contrarreferência. 3. dificuldades na organização das atividades de regulação. 4. baixa utilização / inexistência de protocolos para encaminhamentos. 5. precariedade de sistemas de informação e comunicação. 6. significativa influência política na gestão das unidades de saúde. 7. desorganização da rede de serviços. Conclusão: os desafios elencados sintetizam uma agenda estratégica de gestão, podendo auxiliar os gestores na tomada de decisão, no monitoramento e avaliação.&#x0D; &#x0D; DESCRITORES &#x0D; Regulação.Continuidade da Assistência ao Paciente.Integralidade em Saúde.

The view of experts on initiatives to be undertaken to promote equity in the access to orphan drugs and specialised care for rare diseases in Spain: A Delphi consensus

ObjectivesTo reach a consensus amongst experts on the most feasible actions to be undertaken to facilitate patient access to specialised care and orphan drugs (OD) in the public health sector in Spain. MethodsTwo Delphi rounds were completed. The questionnaire was based on a literature review and 2 focus groups. Agreement was sought on the desire (D) and prognosis (P) for the implementation within the next 5 years, on a 5-point Likert scale. Consensus was reached when ≥75% participants chose agreement (1–2) or disagreement options (4–5). Results82 experts on rare disease (RD) participated. Agreement on the D and P was reached in 66.07% statements: OD pricing review [absence of clinical effectiveness (D:85.37%; P:85.90%), target population increase (D:79.27%; P:91.03%)]; reference team definition of referral protocols and clinical practice guidelines (D: 97.56%; P: 89.74%); and a unified, usable, etiology-based registry (D:97.56%; P:84.62%). D and P assessment diverged in 32.14% items: creation of a specific funding system for OD (D: 97.56%; P: 60.25%); and a network of medical teams to coordinate the care of RD patients (D: 99%; P: 62%). ConclusionsThe results have shown the need to promote dialogue between stakeholders, introduce European recommendation to national and regional Spanish policies and set up priorities and undertake actions to drive relevant changes in current medical practice in managing RD patients.

Informing prehospital care planning using pilot trauma registry data in Yaoundé, Cameroon.

About 54% of deaths in low- and middle-income countries (LMICs) are attributable to lack of prehospital care. The single largest contributor to the disability-adjusted life years due to poor prehospital care is injury. Despite having disproportionately high injury burdens, most LMIC trauma systems have little prehospital organization. An understanding of existing prehospital care patterns in LMICs is warranted as a precursor to strengthening prehospital systems. In this retrospective pilot study, we collected demographic and injury characteristics, therapeutic itinerary, and transport data of patients that were captured by the trauma registry at the Central Hospital of Yaoundé (CHY) from April 15, 2009 to October 15, 2009. Bivariate and multivariate regression analyses were used to explore relationships between care-seeking behavior, method of transport, and predictor variables. The mean age was 30.2years (95% CI [29.7, 30.7]) and 73% were male. Therapeutic itinerary was available for 97.5% of patients (N = 2855). Nearly 18.7% of patients sought care elsewhere before CHY and 82% of such visits were at district hospitals or health clinics. Moderately (OR 1.336, p = 0.009) and severely (OR 1.605, p = 0.007) injured patients were more likely to seek care elsewhere before CHY and were less likely to be discharged home after their emergency ward visit as opposed to being admitted to the hospital for further treatment (OR 0.462, p < 0.001). Commercial vehicles provided most prehospital transport (65%), while police or ambulance transported few injured patients (7%). Possible areas for prehospital trauma care strengthening include training lay commercial vehicle drivers in trauma care and formalizing triage, referral, and communication protocols for prehospital care to optimize timely transfer and care while minimizing secondary injury to patients.

Adapting an Early Palliative Care Intervention to Family Caregivers of Persons With Advanced Cancer in the Rural Deep South: A Qualitative Formative Evaluation

ContextThere is a scarcity of early palliative care interventions to support family caregivers of persons with advanced cancer living in the rural Southern U.S. ObjectiveThe objective of this study was to adapt the content, format, and delivery of a six session, palliative care, telehealth intervention with monthly follow-up for rural family caregivers to enhance their own self-care and caregiving skills. MethodsQualitative formative evaluation consisting of one-on-one, semistructured interviews with rural-dwelling persons with metastatic cancer (n = 18), their primary family caregiver (n = 20), and lay patient navigators (n = 26) were conducted to elicit feedback on a family caregiver intervention outline based on published evidence-based interventions. Transcribed interviews were analyzed using a thematic analysis approach. Coinvestigators reviewed and refined preliminary themes. ResultsParticipants recommended that intervention topical content be flexible and has an adaptable format based on continuous needs assessment. Sessions should be 20 minutes long at minimum, and additional sessions should be offered if requested. Faith and spirituality is essential to address but should not be an overarching intervention theme. Content needs to be communicated in simple language. Intervention delivery via telephone is acceptable, but face-to-face contact is desired to establish relationships. Other Internet-based technologies (e.g., video-conferencing) could be helpful, but many rural dwellers may not be technology savvy or have Internet access. Most lay navigators believed they could lead the intervention with additional training, protocols for professional referral, and supervision by specialty-trained palliative care clinicians. ConclusionsA potentially scalable palliative care intervention is being adapted for family caregivers of rural-dwelling persons with advanced cancer and will undergo piloting in a small-scale randomized controlled trial.

The anti-human trafficking collaboration model and serving victims: Providers’ perspectives on the impact and experience

ABSTRACTPurpose. A coalition model is often used to serve victims of human trafficking but little is known about whether the model is adequately meeting the needs of the victims. The purpose of this study was to examine anti-human trafficking collaboration model in terms of its impact and the collaborative experience, including challenges and lessons learned from the service providers’ perspective. Method. Mixed methods study was conducted to evaluate the impact of a citywide anti-trafficking coalition model from the providers’ perspectives. Web-based survey was administered with service providers (n = 32) and focus groups were conducted with Core Group members (n = 10). Results. Providers reported the coalition model has made important impacts in the community by increasing coordination among the key agencies, law enforcement, and service providers and improving quality of service provision. Providers identified the improved and expanded partnerships among coalition members as the key contributing factor to the success of the coalition model. Discussion. Several key strategies were suggested to improve the coalition model: improved referral tracking, key partner and protocol development, and information sharing.

Clinical presentation, management, and postnatal outcomes of fetal tachyarrhythmias: A 10-year single-center experience.

Background:Limited information is available regarding the prevalence and outcomes of fetal tachyarrhythmias from the developing countries.Aims:This study aims to report referral patterns, management protocols, and pregnancy outcomes of fetuses with tachyarrhythmias reporting to a single center in South India.Methods:All fetuses with documented sustained fetal tachyarrhythmia during the study period (2008–2017) were included. Arrhythmia characterization and hemodynamic evaluation were done using fetal echocardiography. Patients were grouped into supraventricular tachycardia (SVT) and atrial flutter (AF) groups. Patient characteristics, transplacental therapy (TPT), pregnancy, and postnatal outcomes were analyzed.Results:Total of 19 fetuses included; 11 had SVT and 8 AF. Mean gestational age at referral was higher for AF (32.5 ± 3.2 vs. 29.6 ± 3.3 weeks; P = 0.05). Hydrops fetalis was present 8 (42%) fetuses; 4 in each group. TPT was instituted in 18 fetuses; 12 (66.7%) received combination therapy; 4 (21%) received direct fetal therapy. Eighteen fetuses (91%) were born alive with one intrauterine death in a fetus with SVT and severe hydrops. Seven (87.5%) fetuses with hydrops survived. Twelve patients (66.7%) were delivered in sinus rhythm. Six babies (33.3%) had tachycardia at birth requiring anti-arrhythmic therapy. All patients survived the neonatal period. Duration of trans-placental therapy (3.8 + 3.3 vs. 7.3 + 3.4 weeks) was shorter in the AF group.Conclusions:Aggressive TPT using combination of drugs achieves excellent pregnancy and postnatal outcomes in fetuses with tachyarrhythmia. Early diagnosis and prompt referral before hemodynamic decompensation is critical for ensuring optimal outcomes.

Psychosocial predictors of body image dissatisfaction in patients referred for NHS aesthetic surgery

A limited number of studies have researched psychosocial predictors of body image dissatisfaction exclusively within the National Health Service (NHS) aesthetic surgery patient populations, despite aesthetic surgery being offered on an exceptional basis. The Adult Exceptional Aesthetic Referral Protocol (AEARP) defines criteria for aesthetic surgery under the NHS in Scotland. The protocol requires psychological assessment prior to surgery for the majority of aesthetic surgery procedures offered. It is therefore important to establish psychological predictors of body image dissatisfaction to aid with assessment and provision of psychological therapy for this patient group. 334 consecutive potential aesthetic surgery patients referred for psychological assessment under the AEARP completed psychosocial self-report assessment measures as part of routine practice. Multiple regression analysis using the forced entry method was used to investigate psychosocial predictors of body image dissatisfaction. Multiple regression analysis indicated that younger age, greater symptoms of depression, lower levels of self-esteem and greater interpersonal sensitivity significantly predicted higher levels of self-reported body image dissatisfaction. Symptoms of anxiety did not significantly predict body image dissatisfaction. This study indicates that both self perception and perception of self in relation to others, especially fear of being judged by others, significantly relates to body image dissatisfaction in this patient group. Psychological assessment of patients' suitability for aesthetic surgery should consider factors such as the patients' interpersonal functioning. Psychological intervention targeted at symptoms of depression, difficulties with self-esteem and interpersonal functioning may be of significant benefit to patients either prior to undergoing surgery or as an alternative to aesthetic surgery.

Doctors\u2019 opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system

BackgroundClinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors’ opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use.MethodsA qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level.ResultsWith few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms.DiscussionMechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.

Formação de professores de classe hospitalar em saúde mental como resultante de uma pesquisa-ação existencial

This study aims to investigate the health of the hospital class teacher in the state department of education in Goias. The methodology used was existential research-action. As a result of the field research, a training course in mental health was proposed in partnership with the actors and authors of the research with the teachers of the Nucleus of Hospital Educational Attendance, using the Problem-Based Learning (PBL) method, a pedagogical strategy of problem-based learning that focuses on student-centered learning. The effective, collaborative and engaged participation of authors and actors in the research brought, as a result, theoretical and methodological insights on the proposed theme. Reflection on the difficulties in attending cases involving mental disorder, greater knowledge about mental illness and its reflexes on behavior, clarification on action procedures and construction of referral protocols.

A Longitudinal Study of Health Care Resources, Family Support, and Mental Health Outcomes Among Suicidal Adolescents

AbstractTo inform current public policy regarding suicide prevention, this study examined the longitudinal relationships between four resources (public insurance, primary care services, school‐based mental health treatment, and family support) and depression and suicidality in a nationally representative sample of suicidal adolescents (n= 1,355). Longitudinal regression analyses were conducted using data from three waves of the National Longitudinal Study of Adolescent to Adult Health (Add Health). Parental support at Wave I was predictive of lower levels of depression across all three waves, but not significantly associated with the suicide‐specific outcomes. While type of insurance was not significantly associated with any of the outcomes, receipt of public assistance was associated with a higher likelihood of suicidal ideation and higher levels of depression at all three waves. Neither receipt of a routine physical nor access to school‐based mental health treatment were associated with any of the outcomes. Intervention points for future policy that are discussed include the following: integrating family interventions into current screening and referral protocols, targeted screening and outreach for those youth and young adults receiving public assistance, the inclusion of integrated behavioral health in primary care settings, and the inclusion of suicide‐specific evidence‐based treatments in the school setting.

Sustainability of an early detection program for autism spectrum disorder over the course of 8 years.

The importance of early detection of autism spectrum disorder followed by early intervention is increasingly recognized. This quasi-experimental study evaluated the long-term effects of a program for the early detection of autism spectrum disorder (consisting of training of professionals and use of a referral protocol and screening instrument), to determine whether the positive effects on the age at referral were sustained after the program ended while controlling for overall changes in the number of referrals. Before, during, and after the program, the proportion of children referred before 3 years (versus 3–6 years) of age was calculated for children subsequently diagnosed with autism spectrum disorder (N = 513) or another, non-autism spectrum disorder, condition (N = 722). The odds of being referred before 3 years of age was higher in children with autism spectrum disorder than in children with another condition during the program than before (3.1, 95% confidence interval: 1.2–7.6) or after (1.7, 95% confidence interval: 1.0–3.0) the program but was not different before versus after the program. Thus, although the program led to earlier referral of children with autism spectrum disorder, after correction for other referrals, the effect was not sustained after the program ended. This study highlights the importance of continued investment in the early detection of autism spectrum disorder.

Nurses’ knowledge about and attitudes toward organ donation in state and private hospitals in Johannesburg, South Africa

Background . Nurses are intricately involved in organ donation; however, the referral of donors appears to be declining in Johannesburg, South Africa (SA). This may be due to barriers in the referral process. Objectives . The objectives of this study were to explore nurses’ knowledge of the organ donation process and to explore personal beliefs and attitudes around organ donation. Methods . A quantitative, self-administered questionnaire was completed by nurses in Johannesburg, SA. Results. A total of 273 nurses participated, of whom most were female and <50 years old. The majority of participants (64.2%) reported positive attitudes, and 63.2% stated that their personal beliefs about organ donation did not influence the advice they gave to patients. However, only 36.8% felt confident referring potential donors and 35.8% felt that referral was within their scope of practice. Most participants (84.5%) felt that it was the doctor’s responsibility to refer donors, but 80.3% noted that they would refer donors themselves if there was a mandatory referral protocol. Only 61% of nurses were aware that there was access to a transplant procurement coordinator through their hospitals; however, there was uncertainty regarding the role of the coordinator. Conclusion . There is an urgent need to clarify the role of nurses in the process of organ donor referral in SA. Although nurses felt positive about organ donation, they expressed uncertainties about referring potential donors. However, if a clear protocol for referral was introduced, the majority of nurses noted that they would willingly follow it. We advocate for the development and implementation of a nationally endorsed protocol for donor referral and for the training of nurses in organ donation in SA.

How and when to refer patients diagnosed with primary headache and craniofacial neuralgia in the emergency department or primary care: Recommendations of the Spanish Society of Neurology's Headache Study Group

IntroductionWhen a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential, or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected.In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. DevelopmentYoung neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with the Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. ConclusionsWe hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

How and when to refer patients diagnosed with secondary headache and other craniofacial pain in the emergency department and primary care: Recommendations of the Spanish Society of Neurology's Headache Study Group

IntroductionWhen secondary headache is suspected and the patient is referred to the emergency department or to the outpatient neurology clinic, it is important to know which are the appropriate complementary examinations to perform and the suitable referral pathway for patients to follow.In order to establish recommendations on this matter, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to issue a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgias. DevelopmentYoung neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with GECSEN's Executive Committee. For practical reasons, the document was divided into 2 articles: the first focuses on primary headaches and craniofacial neuralgias and this second article on secondary headaches and other craniofacial pain. In order for the recommendations to be helpful for daily practice, they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. ConclusionsWe hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

Distress and satisfaction with research participation: Impact on retention in longitudinal disaster research

Previous studies of the impact of post-trauma research participation indicate that while the research experience may be emotional, it can still be valued by participants. This paper describes participant experiences of the Australian post-bushfire research study–Beyond Bushfires. It examines the relationships between distress during research participation, probable mental health conditions, and satisfaction with the research experience over time.A range of strategies was incorporated into the study, including a distress and risk assessment and referral protocol, to minimise any risk of harm for people who had experienced the 2009 bushfires and their aftermath. Participants included 1056 respondents (Wave 1) interviewed via telephone and web-based survey between December 2011 through January 2013, and 736 (76.1%) of the participants were re-surveyed between July and November 2014 (Wave 2). Research impact was monitored through two questions about survey experience on each occasion. Reported distress at completing the survey was generally low, while overall satisfaction was relatively high. Participants’ reported satisfaction was not associated with their reported level of distress as a result of the survey; and reported participation distress at Wave 1 did not predict whether a respondent would return to complete the survey at Wave 2. Fire-related Posttraumatic stress symptoms were associated with increased satisfaction and likelihood to return at Wave 2.These findings suggest that for Beyond Bushfires survey respondents the perceived benefits outweighed the costs of participation over time.

Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología

IntroductionWhen secondary headache is suspected and the patient is referred to the emergency department or to the outpatient neurology clinic, it is important to know which are the appropriate complementary examinations to perform and the suitable referral pathway for patients to follow.In order to establish recommendations on this matter, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to issue a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgias. DevelopmentYoung neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with GECSEN's Executive Committee. For practical reasons, the document was divided into 2 articles: the first focuses on primary headaches and craniofacial neuralgias and this second article on secondary headaches and other craniofacial pain. In order for the recommendations to be helpful for daily practice, they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. ConclusionsWe hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

Cómo y cuándo derivar un paciente con cefalea primaria y neuralgia craneofacial desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología

IntroductionWhen a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected.In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. DevelopmentYoung neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. ConclusionsWe hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

A Framework for Implementing the National Diabetes Prevention Program in Los Angeles County.

IntroductionPreventing type 2 diabetes is a public health priority in the United States. An estimated 86 million Americans aged 20 years or older have prediabetes, 90% of whom are unaware they have it. The National Diabetes Prevention Program (NDPP) has the potential to reduce the incidence of type 2 diabetes; however, little is known about the best way to institutionalize such a program in a jurisdiction with a racially/ethnically diverse population. The objective of this study was to develop a practice-grounded framework for implementing the NDPP in Los Angeles County.MethodsIn 2015, the Los Angeles County Department of Public Health (LACDPH) partnered with Ad Lucem Consulting to conduct a 3-stage formative assessment that consisted of 1) in-depth interviews with key informants representing community-based organizations to learn about their experiences implementing the NDPP and similar lifestyle-change programs and 2) 2 strategic planning sessions to obtain input and feedback from the Los Angeles County Diabetes Prevention Coalition. LACDPH identified core activities to increase identification of people with type 2 diabetes and referral and enrollment of eligible populations in the NDPP.ResultsWe worked with LACDPH and key informants to develop a 3-pronged framework of core activities to implement NDPP: expanding outreach and education, improving health care referral systems and protocols, and increasing access to and insurance coverage for NDPP. The framework will use a diverse partner network to advance these strategies.ConclusionThe framework has the potential to identify people with prediabetes and to expand NDPP among priority populations in Los Angeles County and other large jurisdictions by using a diverse partner network