Referral Setting Research Articles

Prospective Feasibility and Revalidation of the Equine Acute Abdominal Pain Scale (EAAPS) in Clinical Cases of Colic in Horses.

Simple SummarySeverity of pain, an important parameter in clinical decision making, is subjective. The Equine Acute Abdominal Pain Scale (EAAPS) was evaluated for the first time in 237 horses presenting with colic (abdominal pain) at two equine hospitals; in Israel and in the United Kingdom. The EAAPS demonstrated validity and was reportedly quick and easy to use. The EAAPS is the only equine pain scale that has been tested to this extent for these properties on clinical cases in equine hospitals. Use of the EAAPS apparently requires no training, is easy to use in clinical cases, and can improve equine welfare.Assessment of the severity of pain in colic cases is subjective. The Equine Acute Abdominal Pain Scale (EAAPS), previously validated using film clips of horses with colic, was tested for feasibility and revalidated in both medical and surgical colic cases in Israel and the UK. Feasibility qualities evaluated were quickness and ease-of-use. Pain in 231 horses, presented for colic, was assessed by 35 participants; 26 in the UK and 9 in Israel. Without prior training, participants assessed the severity of pain using two scales; the EAAPS and a visual analogue scale (VAS). Convergent validity comparing the EAAPS to the VAS was substantial, discriminant validity was good, and predictive validity for surgical treatment was similar to the VAS, but for mortality, the VAS was significantly better. No participants reported the EAAPS to be “very slow” or “very difficult” to use. The mode reported was “quick”/“very quick” and “easy”/“very easy” to use, though in less than 10% of cases, it was reported to be a little less quick or easy. More experienced first-time users found it significantly quicker to use than less experienced participants. In conclusion, the EAAPS is the only equine pain assessment scale that has been tested and found to demonstrate good feasibility for use in the referral hospital setting.

Integrating a Web-Based Self-Management Tool (Managing Joint Pain on the Web and Through Resources) for People With Osteoarthritis-Related Joint Pain With a Web-Based Social Network Support Tool (Generating Engagement in Network Involvement): Design, Development, and Early Evaluation.

BackgroundJoint pain caused by osteoarthritis (OA) is highly prevalent and can be extremely debilitating. Programs to support self-management of joint pain can be effective; however, most programs are designed to build self-efficacy and rarely engage social networks. Digital interventions are considered acceptable by people with joint pain. However, many existing resources are not accessible for or developed alongside people with lower health literacy, which disproportionately affects people with OA.ObjectiveThis study aims to design and develop an accessible digital self-management tool for people with joint pain and integrate this with an existing social network activation tool (Generating Engagement in Network Involvement [GENIE]) and to explore the feasibility of these linked tools for supporting the management of joint pain.MethodsThe study was conducted in 2 phases: a design and development stage and a small-scale evaluation. The first phase followed the person-based approach to establish guiding principles for the development of a new site (Managing joint Pain On the Web and through Resources [EMPOWER]) and its integration with GENIE. People with joint pain were recruited from libraries, a community café, and an exercise scheme to take part in 3 focus groups. EMPOWER was tested and refined using think-aloud interviews (n=6). In the second phase, participants were recruited through the web via libraries to participate in a small-scale evaluation using the LifeGuide platform to record use over a 1-month period. Participants (n=6) were asked to complete evaluation questionnaires on their experiences. The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was used to explore the feasibility of the sites.ResultsThe focus groups established guiding principles for the development of the tool. These included ensuring accessibility and relevance for people with OA-related joint pain and recognizing that joint pain is the reason for seeking support, trust, social facilitation, and goal setting. Think-aloud interviews identified issues with user experience and site navigation and the need for professional input for referral and goal setting, confusion, and tensions over the role of GENIE and site connectivity. Participants expected the sites to be specific to their pain-related needs. EMPOWER was accessed 18 times; 6 users registered with the site during the evaluation study. Participants mostly explored information pages on being active and being a healthy weight. Only one participant undertook goal setting and 4 participants visited the GENIE website.ConclusionsUsing the NASSS framework, we identified the complexity associated with integrating EMPOWER and GENIE. The value proposition domain highlighted the technical and conceptual complexity associated with integrating approaches. Although identified as theoretically achievable, the integration of differing propositions may have caused cognitive and practical burdens for users. Nevertheless, we believe that both approaches have a distinct role in the self-management of joint pain.

Delphi consensus recommendations on how to provide cardiovascular rehabilitation in the COVID-19 era.

This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from −5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 ‘for’ and 10 ‘against’ respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

Serum Soluble Interleukin-2 Receptor Does Not Differentiate Complex Regional Pain Syndrome from Other Pain Conditions in a Tertiary Referral Setting.

Previously, we showed that serum soluble interleukin-2 receptor (sIL-2R) levels, a marker for T-cell activation, were higher in complex regional pain syndrome (CRPS) patients than in healthy controls, suggesting pathogenic T-cell activation in CRPS. Additionally, sIL-2R levels discriminated well between CRPS and healthy controls with a high sensitivity (90%) and specificity (89.5%), suggesting a possible role for sIL-2R in the diagnosis of CRPS. In order to further validate this marker in the diagnostic workup of CRPS, we conducted this prospective cohort study in which we determined sIL-2R levels in patients that were referred to our tertiary referral center with a suspicion of CRPS in a limb, and subsequently compared sIL-2R levels between the patients that were diagnosed with CRPS (CRPS group) and those who were not (no CRPS group). A group of anonymous blood bank donors were used as a healthy control group. Furthermore, we explored the relationship between sIL-2R and CRPS disease severity using the CRPS severity score. Median sIL-2R levels of both the CRPS group (2809.0 pg/ml; Q3-Q1: 3913.0-1589.0) and no CRPS group (3654.0 pg/ml; Q3-Q1: 4429.0-2095.5) were significantly higher than that of the control group (1515.0 pg/ml; Q3-Q1: 1880.0-1150.0): CRPS vs. controls, p < .001; no CRPS vs. controls, p < 0.001. Serum sIL-2R levels did not differ significantly between the CRPS and no CRPS group. A statistically significant negative correlation was observed between sIL-2R levels and the CRPS severity score (rs = −0.468, p = 0.024). Our results confirm our previous findings of higher sIL-2R levels in CRPS patients than in healthy controls. We further showed that serum sIL-2R cannot differentiate between CRPS and other pain conditions of a limb in a tertiary referral setting. Interestingly, a negative correlation was found between sIL-2R and CRPS disease severity; this finding warrants further research into the relationship between sIL-2R and CRPS disease severity.

Prevalence of symptoms in patients poisoned with iron in Ahvaz Razi Hospital in 2014-2017

Background: Iron is an important element for normal cell metabolism, but in excess amounts is quite cytotoxic, and even deadly. Iron poisoning is a calamity repeated many times in the world. The clinical signs of the patients include gastrointestinal symptoms, a short period of relative stability, Cardiogenic shock, liver failure, and scarring of the gastrointestinal tract. Iron tablets are specifically tempting to children because they are similar to candy. Iron overdose in adults is usually to attempt suicide. Methods: The present study is a descriptive-analytic study based on hospital information, that was conducted among the patients affected with iron poisoning admitted to Razi hospital (a referral medical setting for poisoning treatment in southwest Iran) during 2014-2017. Patient information has been extracted and inserted in the inquiry form and data were analyzed by SPSS software. Results: In this study, 52 patients (94.2% female) were studied. 5 (9.6%) of women were pregnant. The majority of them (69.2%) were between 15-25 years of age. Nausea and vomiting (50%) are two of the most common side effects. 5 patients (9.6%) received deferoxamine. All Patients who received deferoxamine, symptoms had less than 6 hours of onset. Most patients were hospitalized between 6-24 hours. 25% of patients took vitamins simultaneously with iron. The Serum level of iron in 3 patients (5.8%) was above 300 µg/dL. Based on this research, mortality was reported in one patient. Conclusion: In this study, the prevalence of iron poisoning was examined based on demographic and clinical characteristics. Considering the most prevalent iron poisoning in the young age group (96.2% suicides), more research in the psychological and social problems is critical for preventative behaviors.

Fine Needle Aspiration Biopsy of Peripheral Lymph Nodes in Children: Practical Experience in a Tertiary Hospital.

Peripheral lymphadenopathy occurs often in children; fine needle aspiration biopsy (FNAB) is a commonly performed diagnostic procedure. We describe FNAB use and outcome for peripheral lymphadenopathy in children in a routine clinical setting. A retrospective study done at Tygerberg Hospital, Cape Town of children (<13 years) who had an FNAB for lymphadenopathy from July 2012 to June 2014. Demographic, clinical, treatment and follow-up data were retrieved from patient folders; FNAB and special investigation results were obtained from the laboratory database. Of the 173 children, the median age was 37 (interquartile range 13-75) months; 20 (11.5%) were HIV positive. Most FNABs were done in the neck (131; 76%) and axillary areas (34; 20%). FNAB provided a result in 165 (95%) cases; in 8 (5%) children FNAB was insufficient for diagnosis. Mycobacterial aetiology was diagnosed in 84 (49%); 49 (58%) were culture-confirmed (37 Mycobacterium tuberculosis, 10 Mycobacterium bovis BCG, 1 both and 1 non-tuberculous mycobacterium). Reactive lymphadenopathy was diagnosed in 56 (32%), neoplastic disease in 6 (3.5%) and other pathology in 19 (11%) cases. Additional special investigations changed FNAB diagnosis or led to an additional diagnosis in 8 (5%) children. Overall, 70/84 (83%) with mycobacterial aetiology and all neoplastic disease cases received the correct treatment. Follow-up appointments were arranged in 144 (83%) patients. In a high tuberculosis burden area, a single FNAB provided a diagnosis in most cases in a routine referral setting; FNAB remains a safe and useful investigation. Follow-up of children to initiate appropriate treatment could improve. Large swollen lymph nodes, especially in the neck, are a common finding in children. Fine needle aspiration biopsy (FNAB) is a commonly used diagnostic procedure and we looked at how well this procedure works in everyday hospital practice. We identified all children <13 years of age over a 2-year period (2012-2014) who had an FNAB done at Tygerberg Hospital, Cape Town, South Africa, and looked how well this procedure performed and what the doctors did with these children. We found 173 children who had an FNAB done. They were generally young children of around 3 years old. With a single FNAB, we could make a diagnosis in 95% of these children. About half of the children had tuberculosis or complications of a BCG vaccine (both caused by mycobacteria), only 4% had a malignancy of some kind, about a third had reactive lymph nodes (usually other mainly local infectious causes) and the rest had other pathology like abscesses. All malignancies and >80% of the mycobacterial pathology cases were correctly managed; the latter could definitely improve.

Evaluation of an Interdisciplinary Screening Program for People With Parkinson Disease and Movement Disorders

ObjectiveTo describe the characteristics of people with Parkinson disease and movement disorders (PDMDs) referred by neurologist to a physiatrist-led interdisciplinary rehabilitation screening program. DesignRetrospective data analysis of electronic health records (EMRs). SettingOutpatient PDMD neurology clinic and an interdisciplinary rehabilitation hospital’s PDMD screening program. ParticipantsPeople with PDMDs referred by neurologists to the interdisciplinary rehabilitation screening program from 2009-2017 (n=934), with early referrals from 2009-2015 (n=449) and recently referred from 2015-2017 (n=485), and patients who had new interdisciplinary rehabilitation screening program evaluations from 2015-2017 (n=183). InterventionParticipation in the physiatrist-led PDMD screening clinic. Main Outcome MeasuresDemographics, disease-related features, timed Up and Go, conversational voice volume, recommended therapy services, and number of therapies completed 90 days following interdisciplinary rehabilitation screening program. ResultsPeople referred from the neurologists to the interdisciplinary rehabilitation screening program from 2009-2017 were 72±12.9 years old, male (56%), white (65%), and with 1 or more comorbidities (62%). Compared with early referrals from 2009-2015, more recently referred participants from 2015-2017 were younger (P<.001) and earlier in disease duration (P=.036). The interdisciplinary rehabilitation screening program participants from 2015-2017 had mean timed Up and Go time of 15.4±10.1 seconds and a mean conversational voice volume of 68.98±4.7 dB. ConclusionsThe interdisciplinary rehabilitation screening program was sustained with increased number of referrals over time, occurring earlier in the disease in more recent years. Key strategies used to sustain the program over time include development of a unique referral order set for the neurologists, implementation of a comprehensive screen tool in the rehabilitation hospital EMR, and centralized communication through social workers at both facilities.

Unsuspected choledocholithiasis found by routine intra-operative cholangiography during laparoscopic cholecystectomy.

The true incidence of unsuspected choledocholithiasis found during laparoscopic cholecystectomy (LC) is unknown. Untreated 'silent' stones may be associated with significant long-term risks. The aim of this study was to establish the incidence of unsuspected common bile duct stones (CBDS) and to determine the management and associated risk factors for unsuspected CBDS. Retrospective review of a large consecutive series of patients from Australia who underwent LC in a tertiary referral setting. Percentages of unsuspected CBDS, management and complications were reported. Pre-operative and intra-operative factors associated with unsuspected CBDS were determined using multivariable logistic regression analysis. From a total of 1998 patients who underwent LC, 747 (37.4%) patients with no pre-operative suspicious factors were the subject of this study. CBDS were detected in 24 (3.2%) patients and all were managed either laparoscopically or endoscopically. Risk factors independently associated with unsuspected CBDS included patients >55 years of age (odds ratio 2.93, P = 0.038) and a large cystic duct size (odds ratio = 3.13, P < 0.001) on multivariable analysis. The incidence of patients with unsuspected CBDS on intra-operative cholangiography is low. Complete clearance of these stones can be achieved using a combination of laparoscopic and endoscopic methods.

Referral-to-treatment attrition and its impact on outcomes of patients with advanced gastroesophageal cancers.

e16504 Background: Advanced gastroesophageal cancers (AGCs) are aggressive tumors. Prior research has demonstrated that patients with poor prognostic cancers are inconsistently or infrequently referred to oncology specialists because of misperceptions that oncologic treatments are futile and do not alter overall outcomes. The aim of this real-world study was to characterize the attrition of patients with AGCs as they proceed through the diagnostic-therapeutic pathway and to assess its impact on survival. Methods: A retrospective population-based analysis was performed using data from the cancer registry and electronic medical records in a large province (Alberta, Canada). Patients diagnosed with AGCs from 2010 to 2017 were included. Details on demographics, setting of referral (outpatient or inpatient), time from referral to consultation to treatment, and modality of treatment (best supportive care, systemic therapy, and/or radiation) were collected. Logistic regression was used to determine factors associated with referral. Cox regression models were constructed to determine factors associated with overall survival (OS). Results: We identified 1,244 patients, of whom 633 (51%) had gastric and 611 (49%) had esophageal cancer. Median age was 67 years (IQR 58-78 years) and 72% were men. In this cohort, 87% were referred to a cancer center, 80% were seen by an oncologist, and only 44% received first-line treatment. Median time from referral to consultation was 13 days and consultation to treatment was 12 days. In logistic regression, advanced age (OR 0.274; 95% CI 0.183-0.412, p&lt;0.0001) and those with a gastric primary (OR 0.437; 95% CI 0.303-0.628, p&lt;0.0001) were less likely to be referred. In Cox regression, receipt of chemotherapy (HR 0.79; 95% CI 0.76-0.83, p&lt;0.0001) and shorter time from consultation to treatment (HR 0.994; 95% CI 0.991-0.997, p&lt;0.0001) were predictive of better OS. The setting of referral (inpatient vs. outpatient) was not significantly associated with OS (HR 1.11; 95% CI 0.85-1.45, p=0.414). Conclusions: Attrition was most significant as patients proceeded from consultation to treatment. Streamlining processes to narrow the consultation to treatment window may increase the number of patients with AGCs who may be eligible for potentially effective therapies or new clinical trials, which can improve their overall outcomes.

Screening for primary hyperparathyroidism in a tertiary stone clinic, a useful endeavor.

Primary hyperparathyroidism (1HPT) is associated with the risk of developing kidney stones. Our objective was to determine the prevalence of 1HPT amongst SF evaluated at a tertiary stone clinic and determine if it is cost-effective to screen for this condition. We retrospectively reviewed 742 adult SF seen by a single urologic surgeon from 2012 to 2017 all of who were screened for 1HPT with an intact serum PTH (iPTH) and calcium. The diagnosis of 1HPT was based on the presence of hypercalcemia with an inappropriately elevated iPTH or a high normal serum calcium and an inappropriately elevated iPTH. The diagnosis was confirmed by surgical neck exploration. Published cost data and stone recurrence rates were utilized to create a cost-effectiveness decision tree. Fifty-three (7.1%) were diagnosed with 1HPT. 15 (28%) had hypercalcemia and inappropriately elevated iPTH, 38 (72%) had high normal serum calcium levels and inappropriately elevated iPTH. The potential diagnosis was ignored/missed by primary care physicians in 9 (17.0%) based on a review of prior lab results. Cost modeling was undertaken for 5, 10, 15, and 20-year intervals after screening. Based on our prevalence data, historical risks for recurrence and published cost data for stone treatments, cost savings in screening are realized at 10years. These results support screening for primary hyperparathyroidism in patients evaluated in a tertiary referral setting.

Herpes Simplex virus type 2 seroprevalence and risk factors among adolescents and youth with HIV-1 in Northern, Tanzania.

Herpes Simplex virus type 2 (HSV-2) infection is associated with an increased risk of human immunodeficiency virus type 1 (HIV-1) acquisition and transmission. Individuals co-infected with HIV-1 and HSV-2 may have longer lasting, more frequent and severe outbreaks of herpes symptoms. Previous studies have assessed HSV-2 seroprevalence and associated risk factors in adult populations. However, there is limited data on the HSV-2 seroprevalence among adolescents and youth living with HIV-1. The study aimed to determine the HSV-2 seroprevalence and associated risk factors among adolescents and youth living with HIV-1 at referral hospital setting in Northern Tanzania. A cross-sectional survey was conducted between February and July 2017 among HIV-1-infected individuals aged 10-24 years attending the Child -Centred Family Care Clinic at Kilimanjaro Christian Medical Centre. Blood specimens from 180 individuals were collected for ELISA-based detection of HSV-2 antibodies. Associations between risk factors and HSV-2 seroprevalence were analysed by univariate and multivariate logistic regression models. The overall HSV-2 seroprevalence was 18% (32/180). A significant HSV-2 seroprevalence was noted among adolescents and youth, who reported having had sexual intercourse than those who never had sexual intercourse (28.9% vs 13.3%, p = 0.02). Youths aged 20-24 had six folds higher risk of HSV-2 seroprevalence compared to those aged 10-14 years (AOR = 5.97 95% CI 1.31 - 27.19, p = 0.02). Our study found that HSV-2 seroprevalence increased by age among adolescents and youth living with HIV-1. Age-specific approaches might play an important role in interventions targeting HSV-2 infection.

Effect of Face-Down Positioning vs Support-the-Break Positioning After Macula-Involving Retinal Detachment Repair

A lack of consensus exists with regard to the optimal positioning regimen for patients after macula-involving retinal detachment (RD) repair. To evaluate the effect of face-down positioning vs support-the-break positioning on retinal displacement and distortion after macula-involving RD repair. A prospective 6-month single-masked randomized clinical trial was conducted at a multicenter tertiary referral setting from May 16, 2016, to May 1, 2018. Inclusion criteria were fovea-involving rhegmatogenous RD; central visual loss within 14 days; patients undergoing primary vitrectomy and gas surgery, under local anesthetic; patients able to give written informed consent; and 18 years old and older. Analysis was conducted following a modified intention-to-treat principle, with patients experiencing a redetachment or failure to attach the macula being excluded from analysis. Participants were randomized 1:1 to receive face-down positioning or support-the-break positioning for a 24-hour period postoperatively. Positioning compliance was not monitored. The proportion of patients with retinal displacement on autofluorescence imaging at 6 months postoperatively. Secondary outcomes included proportion of patients with displacement at 2 months; amplitude of displacement at 2 and 6 months; corrected Early Treatment Diabetic Retinopathy Study visual acuity; objective Distortion Scores; and quality of life questionnaire scores at 6 months. Of the 262 randomized patients, 239 were analyzed (171 male [71.5%]; mean [SD] age, 60.8 [9.8] years). At 6 months, retinal displacement was detected in 42 of 100 (42%) in the face-down positioning group vs 58 of 103 (56%) in the support-the-break positioning group (odds ratio, 1.77; 95%CI, 1.01-3.11; P = .04). The degree of displacement was lower in the face-down group. Groups were similar in corrected visual acuity (face-down, 74 letters vs support-the-break, 75 letters), objective D Chart Distortion Scores (range: 0, no distortion to 41.6, severe distortion; with face-down at 4.5 vs support-the-break at 4.2), and quality of life scores (face-down 89.3 vs support-the-break 89.0) at 2 and 6 months. Retinal redetachment rate was similar in both groups (face-down group, 12.2% and support-the-break group, 13.7%). Retinal folds were less common in the face-down positioning group vs the support-the-break positioning group (5.3% vs 13.5%, respectively; odds ratio, 2.8; 95% CI, 1.2-7.4; P = .03). Binocular diplopia was more common in the support-the-break group compared with the face-down positioning group (7.6% vs 1.5%, respectively; odds ratio, 5.3; 95% CI, 1.3-24.6; P = .03). Amplitude of displacement was associated with worse visual acuity (r = -0.5; P < .001) and distortion (r = 0.28; P = .008). In this study, findings suggest that face-down positioning was associated with a reduction in the rate and amplitude of postoperative retinal displacement after macula-involving RD repair and with a reduction in binocular diplopia. No association was found with visual acuity or postoperative distortion. ClinicalTrials.gov Identifier: NCT02748538.

P90 Streamlining primary care referrals to an early inflammatory arthritis (EIA) clinic: distinguishing between patients with osteoarthritis and inflammatory arthritis

Abstract Background To use biochemical markers and ultrasound to differentiate between inflammatory and noninflammatory diagnoses in the early inflammatory arthritis (EIA) referral setting. Careful patient selection is crucial to ensure timely and efficient use of secondary care resources. Methods A retrospective audit of the EIA pathway was conducted over six months at two partnered district general hospitals in London in 2018. For each of the 75 patients studied, data collected included demographics, biomarkers of disease and inflammation, appointments dates, details of scans requested, and the clinical diagnosis made at the EIA appointment. Statistical tests included pairwise comparisons using Welch’s 2-sample t-test for continuous variables and two-sample chi squared tests for equality of proportions with continuity correction for categorical variables. Logistic regression models were used, incorporating age, inflammatory markers and serostatus. Goodness of fit was evaluated using the log likelihood method and McFadden’s pseudo-R2. Predictive modelling was carried out using the Caret package. Analysis was conducted in R (R v3.5). Results Over half of participants (59%) were diagnosed with non-inflammatory disorders; the most common diagnosis was osteoarthritis (31%). Rheumatoid Arthritis (15%) was most common amongst the 41% of Inflammatory arthritides (IA). Ultrasound confirmed the clinical diagnosis of IA vs non-IA with 70% accuracy. There were no significant differences between those with and without ultrasound evidence of synovitis in terms of age (p 0.25), CRP (p 0.22), ESR (p 0.59), RF (p 0.43) or CCP (p 1) positivity. This null is likely due to a small sample size and lack of statistical power. Comparison of patients with a clinical diagnosis of IA vs non-IA revealed significantly increased CRP (9.5 vs 4.2 p 0.01) and CCP positivity rates (22.5% vs 0%, p 0.003) in the inflammatory group, with no significant differences in age (p 0.45), ESR (p 0.24), or RF positivity rate (p 0.18). In those with a clinical diagnosis of osteoarthritis, there were a significantly higher age (55.0 vs 43.5, p 0.0009), lower CRP (3.2 vs 7.8, p 0.005), and lower ESR (9.2 vs 19.7, p 0.006). Neither RF (p 0.73) nor CCP (p 0.16) positivity rates differed significantly between osteoarthritis or other diagnoses. Conclusion It was demonstrated that even in small cohorts, simple predictive variables can be used to risk-stratify and assess the likelihood that a patient will have osteoarthritis rather than IA. It is shown that older age, lower ESR and lower CRP are indicators at differentiating IA from non-IA. Given the national high prevalence of osteoarthritis and the clinical uncertainty in distinguishing osteoarthritis from IA, ultrasound has significant value in the diagnostic work-up. Further research should attempt to predict eventual diagnosis from clinical characteristics alone to help general practitioners distinguish patients with IA from those with non-IA. Disclosures B.M. Jacobs None. N. Sarathchandra None. M. Karela None. L.E. Daniels None. N. Purkayastha None.

Implementation of an Anaesthesia Quality Improvement Programme to Reduce Fibreoptic Bronchoscope Repair Incidents.

Background This study was aimed at investigating the effectiveness of the implementation of a comprehensive quality improvement programme (QIP) for reducing the repair rate of the fibreoptic bronchoscope (FOB). Methods A three-stage improvement strategy was implemented between January 2013 and December 2016. Stage one is the acquisition of information on violations of practice guidelines, repair rate, cost of repair, and incidence of unavailability of FOB during anaesthesia induction of the previous year through auditing. Stage two is the implementation of a quality improvement campaign (QIC) based on the results of stage one. Stage three is the programme perpetuation through monitoring compliance with policy on FOB use by regular internal audits. The effectiveness was retrospectively analyzed on a yearly basis. Results The annual repair rate, repair cost, and incidence of FOB unavailability before the QIP implementation were 1%, 18,757 USD, and 1.4%, respectively. After QIC, the repair rate in 2013 dropped by 81% (from 1% in 2012 to 0.19% in 2013, p < 0.05). The annual repair cost fell by 32% from 18,758 USD (2012) to 12,820 USD (2013). Besides, the incidence of FOB unavailability plummeted by 71% from 1.4% to 0.4% during the same period. The annual repair rates and incidence of FOB unavailability remained lower in subsequent three years than those before QIP implementation. Conclusion Implementation of a quality improvement programme was effective for reducing the rate and cost of FOB repair as well as unavailability rate, highlighting its beneficial impact on cost-effectiveness and patient safety in a tertiary referral center setting.

Diet and functional dyspepsia: Clinical correlates and therapeutic perspectives.

Hypervigilance and symptoms anticipation, visceral hypersensitivity and gastroduodenal sensorimotor abnormalities account for the varied clinical presentation of functional dyspepsia (FD) patients. Many patients recognize meals as the main triggering factor; thus, dietary manipulations often represent the first-line management strategy in this cohort of patients. Nonetheless, scarce quality evidence has been produced regarding the relationship between specific foods and/or macronutrients and the onset of FD symptoms, resulting in non-standardized nutritional approaches. Most dietary advises are indeed empirical and often lead to exclusion diets, reinforcing in patients the perception of “being intolerant” to food and self-perpetuating some of the very mechanisms underlying dyspepsia physiopathology (i.e., hypervigilance and symptom anticipation). Clinicians are often uncertain regarding the contribution of specific foods to dyspepsia physiopathology and dedicated professionals (i.e., dietitians) are only available in tertiary referral settings. This in turn, can result in nutritionally unbalanced diets and could even encourage restrictive eating behaviors in severe dyspepsia. In this review, we aim at evaluating the relationship between dietary habits, macronutrients and specific foods in determining FD symptoms. We will provide an overview of the evidence-based nutritional approach that should be pursued in these patients, providing clinicians with a valuable tool in standardizing nutritional advises and discouraging patients from engaging into indiscriminate food exclusions.

Learning curve for detection of pelvic parts of ureters by transvaginal sonography: feasibility study.

To investigate how many examinations it takes to be able to identify the pelvic parts of the ureters on transvaginal sonography (TVS). This was a prospective study including consecutive women attending a gynecological outpatient clinic in a tertiary referral setting. Prior to commencement of the study, three trainees, with a focus on gynecological surgery and TVS but with no experience in identifying ureters, each observed an expert examiner performing 10 routine TVS examinations, including identification of both ureters. All were standardized gynecological TVS examinations, with visualization of the pelvic part of both ureters. Consecutive women were then examined, first by the expert, unobserved by the trainees, and then by one of the three trainees, in the presence of the expert. To ensure that identification of the pelvic parts of the ureters could be incorporated feasibly into routine gynecological TVS in a tertiary referral setting, a time limit of 150 s was set for successful identification of each ureter. A successful examination was defined by identifying both ureters within the time limit. The number of women examined by each trainee was determined by how quickly they achieved proficiency, which was evaluated using the learning curve cumulative summation (LC-CUSUM) score. Between January 2017 and June 2017, a total of 140 women were recruited for the study, with 135 patients being included in the final analysis. The three trainees were able to identify the right ureter after a maximum of 48 (range, 34-48) TVS examinations, and the left ureter after a maximum of 47 (range, 27-47) TVS examinations. Sonographers and/or gynecologists who are familiar with gynecological TVS should be able to become proficient in identifying both ureters after 40-50 TVS examinations. Detection of the ureters is a feasible part of the TVS workup of patients attending a clinic in a tertiary referral center. © 2019 the Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Corneal Decompensation in Uveitis Patients: Incidence, Etiology, and Outcome

ABSTRACT Purpose: To identify the prevalence, etiology, management and visual outcomes of treatment in uveitis-related corneal decompensation. Patients and methods: This is a retrospective study of patients with corneal decompensation identified from a large cohort with uveitis in a tertiary referral clinic setting. Results: Between March 1991 and May 2018, 4132 new patients with uveitis were seen in Manchester Uveitis Clinic. Of these, 25 patients (0.6%) were identified with corneal decompensation of which 9 (0.2%) were affected bilaterally (total 34 eyes). The mean interval between uveitis diagnosis and decompensation was 23 months (range 0-117 m). Ten patients (41%) had associated glaucoma. Seventeen eyes (50%) had undergone intraocular surgery prior to decompensation. For eyes with no history of raised intraocular pressure or intraocular surgery, keratouveitis (presumed autoimmune or tuberculous) was the most common cause of corneal decompensation. Fourteen eyes (41%) required corneal graft and of these, five required repeat grafting. Conclusions: Corneal decompensation in eyes with uveitis is a rare but significant complication. Direct endothelial inflammation may alone cause decompensation, but in most eyes with uveitis, prior raised intraocular pressure or intraocular surgery are required to precipitate the cornea into decompensation. Outcomes of corneal transplantation in this group may be disappointing.

Travel Avoidance Using Telepediatric by Patients and Healthcare Providers: a Review of the Literature.

Introduction:Telepediatric is one of the subspecialties of telemedicine that can be defined as the use of information and communication technology tools to offer healthcare services to children at a distance.Aim:The use of telepediatric healthcare services for children living in rural or deserved areas may reduce the cost and time of travel to access these services. This study aims to review published papers that assess the percentage of avoided travel or referrals with the use of telepediatric.Methods:This is a systematic review study. PubMed database was searched in September 2019 to retrieve the published papers. The final 24 retrieved papers were assessed based on the variables such as modality, referral setting, specialty, continent, weight, and percentage of avoided travel. The multivariate linear regression model was used to estimate the percentage of travel avoidance by telepediatric.Results:The linear regression model was determined based on the provided specialty for telepediatric (cardiology, general (multi), and other (rehabilitation, dermatology, psychiatry, respiratory)) with R2 =0.41. The results showed that the mean percentage of avoided travel in cardiology specialty as a baseline was 56%. The use of telepediatric in the general (multi) and other specialties can avoid travel for 26.5% (p=0.02) and 85% (p=0.03) respectively.Conclusion:This study showed that telepediatric could reduce travel at least 26.5% and maximal 85%. These results can be used by healthcare providers to decide on the implementation of successful telepediatric systems to reduce referrals.

Perspectives of Nunavut patients and families on their cancer and end of life care experiences

ABSTRACT The present study arose from a recognition among service providers that Nunavut patients and families could be better supported during their care journeys by improved understanding of people’s experiences of the health-care system. Using a summative approach to content analysis informed by the Piliriqatigiinniq Model for Community Health Research, we conducted in-depth interviews with 10 patients and family members living in Nunavut communities who experienced cancer or end of life care. Results included the following themes: difficulties associated with extensive medical travel; preference for care within the community and for family involvement in care; challenges with communication; challenges with culturally appropriate care; and the value of service providers with strong ties to the community. These themes emphasise the importance of health service capacity building in Nunavut with emphasis on Inuit language and cultural knowledge. They also underscore efforts to improve the quality and consistency of communication among health service providers working in both community and southern referral settings and between service providers and the patients and families they serve.

Suggested modification of Janus associated kinase 2-tree algorithm for the detection of Janus associated kinase 2 V617F-positive polycythemia rubra vera patients in Pakistani population

OBJECTIVE: The Janus associated kinase-2 (JAK2 mutation V617F and exon 12) is detected in most polycythemia vera (PV) patients. It can easily be picked up by real-time polymerase chain reaction (PCR). This technique is easy to perform and is very sensitive requiring minimally invasive techniques. The decision when to order JAK2 mutation test by PCR is important to curb its wastage. To save precious laboratory resources, a peripheral blood finding-based algorithm adjusted to hemoglobin levels of patients (PV) in Pakistan has been purposed, which is a modification of algorithm recently developed by Mahe et al. for the rationalization of JAK2 analysis.METHODS: To assist with the screening of patients being considered for JAK mutation for PV patients in the Pakistani population, we modified clinical decision rule “JAK2-tree” as modified JAK2-tree based on patients' full blood count.RESULTS: We tested both classical and modified JAK2-tree algorithms on two independent data sets, one an unselected population-based sample comprising 51 individuals and other on historical clinical laboratory referral set comprising 51 JAK2-positive cases of PV. Sensitivity for both the algorithms was calculated and compared.CONCLUSION: Our work supports a “modified” decision-tree-based screening approach for Pakistani population to optimize the selection of patients most appropriate for JAK2 V617F testing.