Referral Source Research Articles

A case study of the impact of a dietitian in the multi-disciplinary team within primary care: a service evaluation.

Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload. A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team. This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management. The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

VA family service access and utilization in a national sample of veterans.

Relationship and family difficulties are common experiences for military veterans, who are able to access family services (i.e., couple and family therapy) through the Veterans Affairs (VA) Healthcare System. This study examines demographic, mental health, military, and referral source variables associated with referral to and utilization of family services using a large national VA dataset of 22,969 veterans who were referred to couple or family therapy from 2016 to 2019. Of those referred, 44.39% had a completed referral; among those who initiated therapy, 31.11% attended five or more sessions. Logistic regression was used to evaluate predictors of completed referrals and of attending five or more sessions of couple or family therapy. Veterans identifying as Black/African American, American Indian or Alaska Native were less likely to have a completed referral than non-Hispanic White veterans; moreover, veterans identifying as Black/African American or Hispanic were less likely to attend five or more sessions. Lower likelihood of a completed referral was also associated with rural county residence, being separated, post-9/11 service era, a substance use disorder diagnosis, and being referred by a psychiatrist, neurologist, physician, or nursing staff rather than a psychologist. Lower likelihood of attending five or more sessions was associated with a delay of 22 or more days to intake, an adjustment disorder diagnosis, and being referred from VA specialty care, or by a psychiatrist or neurologist. These findings may help inform efforts for outreach and service retention within VA family services in order to ensure equity in access to care and healthcare utilization. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

Infant Feeding Experiences of Women Who Recovered From Anorexia Nervosa

ObjectiveTo describe the infant feeding experiences of women who recovered from anorexia nervosa (AN). DesignDescriptive phenomenology. SettingPersonal interviews. ParticipantsSixteen women with histories of AN. MethodsI used Colaizzi’s descriptive phenomenological method. In individual audio-recorded interviews, I asked participants to describe their experiences of being mothers who recovered from AN and how this affected feeding their infants. ResultsThe direct and indirect effects of histories of AN permeated the participants’ infant feeding experiences. Participants did not anticipate the overarching challenges of infant feeding in relation to AN, and nurses and clinicians lack guidelines for screening and management. I coded and analyzed 16 transcripts that revealed five overarching themes: Unbound: My Past Does Not Have to Predict the Future, Navigating the Rollercoaster of Pregnancy and the Postpartum Body, Ripples of Trauma in Infant Feeding, The Maddening Maze: Remnants of Anorexia, and Perfectly Imperfect: Recovery and Mothering. ConclusionResults elucidate the complexity of the infant feeding experiences of women who recovered from AN and the importance of screening for a history of AN. Nurses and women’s health care providers should discuss the implications of such a history on prenatal planning, pregnancy, postpartum recovery, and the overall experience of infant feeding. This may help nurses and clinicians provide care for women with known histories of AN by improving the detection of possible symptoms and identifying referral sources for appropriate intervention.

Assessment of Developmental Language Disorder in Multilingual Children: Results from an International Survey.

The Multilingual-Multicultural Affairs Committee of the International Association of Communication Disorders (IALP) conducted a survey of diagnostic criteria for developmental language disorder (DLD) in multilingual children to discover how clinicians apply terminology and diagnostic criteria to multilingual children in different parts of the world. An international web survey was used to survey 354 participants from 44 countries about their assessment practices, and clinical opinions about assessing multilingual children for DLD. The findings show that most clinicians felt confident in assessing multilingual children, and they applied the DLD terminology and inclusionary criteria to multilingual children with difficulty learning language. Clinicians used different procedures to assess heritage and societal languages. Barriers to access to services included a lack of knowledge by parents and referral sources about services available and typical multilingual development, with additional reasons differing by geographical region. Speech pathologists across the globe have many similarities in the way that they assess multilingual children. Differences may be attributed to clinical experience, professional education, the clinician's role, the system they work in, and the clinician's own language skills. This paper advances knowledge of current clinical practices, which can be used to evaluate frameworks in international and national contexts, with implications for policy and practice to improve access to clinical services.

Psychiatric Referrals in a Tertiary Care Hospital in North India: A Retrospective Study

Background and Aim: There is high prevalence of mental disorders in specialist treatment seekers across specialties. Still, psychiatry referral rates have been found to be very low. A physician refers a patient to psychiatric services for reasons like known case of mental disorder, physical symptoms without adequate explanation, or if the physician feels inadequate in dealing with psychological symptoms. A multi disciplinary approach should be encouraged for the management of such patients, facilitating early recognition and management of psychiatric problems. The aim is to study the sociodemographic variables of psychiatric referrals, reasons and diagnostic categories of psychiatric referrals, and the distribution of psychiatric diagnoses according to reasons and sources of referrals. Materials and Methods: A retrospective hospital based study was conducted in the Department of Psychiatry, Hamdard Institute of Medical Sciences and Research, New Delhi, by analyzing the recorded data of referrals to the Psychiatry Department from various other specialties from January 2019 to March 2020. All referred patients were evaluated by a Psychiatrist (MD Psychiatry) and the diagnosis was made as per the International Statistical Classification of Diseases 10 criteria. The data obtained were analyzed using descriptive statistical methods. Results: This study included 315 psychiatric referrals. The mean age and standard deviation of the entire sample were 37.75 ± 17.63. The referral rate was minimum from January to March 2020. The highest number of referrals was from Medicine Department (66.3%). Among those, the most common diagnoses were that of alcohol dependence (27%). The most common overall reason for referral was substance use (26.2%). The most common psychiatric diagnosis was alcohol dependence (24%). Hypertension was the most common physical comorbidity. The most common diagnosis for known case of psychiatric illness and follow ups were psychotic disorders (27.3% and 26.3%). Conclusion: The findings of this study give us insight that consultation liaison psychiatry should focus on early recognition and wholesome management of psychiatric disorders in patients with physical illness through consultation psychiatry services in general hospital settings.

The Geras virtual frailty rehabilitation program to build resilience in older adults with frailty during COVID-19: a randomized feasibility trial

BackgroundThe Coronavirus (COVID-19) pandemic has exacerbated the risk for poor physical and mental health outcomes among vulnerable older adults. Multicomponent interventions could potentially prevent or reduce the risk of becoming frail; however, there is limited evidence about utilizing alternative modes of delivery where access to in-person care may be challenging. This randomized feasibility trial aimed to understand how a multicomponent rehabilitation program can be delivered remotely to vulnerable older adults with frailty during the pandemic.MethodsParticipants were randomized to either a multimodal or socialization arm. Over a 12-week intervention period, the multimodal group received virtual care at home, which included twice-weekly exercise in small group physiotherapy-led live-streamed sessions, nutrition counselling and protein supplementation, medication consultation via a videoconference app, and once-weekly phone calls from student volunteers, while the socialization group received only once-weekly phone calls from the volunteers. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate the feasibility of the program. The main clinical outcomes were change in the 5-times sit-to-stand test (5 × STS) and Depression, Anxiety and Stress Scale (DASS-21) scores. The feasibility outcomes were analyzed using descriptive statistics and expressed as frequencies and mean percent with corresponding confidence intervals (CI). Analysis of covariance (ANCOVA) was used for the effectiveness component.ResultsThe program enrolled 33% (n = 72) of referrals to the study (n = 220), of whom 70 were randomized. Adoption rates from different referral sources were community self-referrals (60%), community organizations (33%), and healthcare providers (25%). At the provider level, implementation rates varied from 75 to 100% for different aspects of program delivery. Participant’s adherence levels included virtual exercise sessions 81% (95% CI: 75–88%), home-based exercise 50% (95% CI: 38–62%), protein supplements consumption 68% (95% CI: 55–80%), and medication optimization 38% (95% CI: 21–59%). Most participants (85%) were satisfied with the program. There were no significant changes in clinical outcomes between the two arms.ConclusionThe GERAS virtual frailty rehabilitation study for community-dwelling older adults living with frailty was feasible in terms of reach of participants, adoption across referral settings, adherence to implementation, and participant’s intention to maintain the program. This program could be feasibly delivered to improve access to socially isolated older adults where barriers to in-person participation exist. However, trials with larger samples and longer follow-up are required to demonstrate effectiveness and sustained behavior change.Trial registrationClinicalTrials.gov NCT04500366. Registered August 5, 2020, https://clinicaltrials.gov/ct2/show/NCT04500366

Patient Report on the Impact of Coronavirus Disease 2019 and Living With Lung Cancer

IntroductionSeveral studies have highlighted coronavirus disease 2019 (COVID-19)–related disruptions in treatment and care in people living with lung cancer. However, few studies have assessed patient-reported perspectives on treatment disruption. This study aims to report the patient perspectives on the impact of COVID-19, vaccination access, and coverage on people living with lung cancer. MethodsData are from a larger online longitudinal study being run by a lung cancer nonprofit organization, LUNGevity Foundation. The survey is open to all patients living with lung cancer and their caregivers. These analyses focus on data captured in the COVID-19 module and the vaccine questionnaire. Descriptive statistics were computed for categorical and ordinal variables. ResultsOverall, 164 people living with lung cancer completed the COVID-19 module. Of these, 54% reported disruption in access to treatment, appointments, participating in research and clinical trials. Participants living with stage IV disease were likely to be more concerned about COVID-19 (35%) compared with those with stage I, II, and III. More than half (66%) had tested for COVID-19 of this group 88% tested negative. There was a correlation among participants testing positive for COVID-19 and the number of household members who also tested positive for COVID-19. In the sample who completed the vaccine survey, almost all (98%) were vaccinated against COVID-19. When a recommendation came from a health care professional, an oncologist was the most likely referral source (33%). ConclusionsAn integrative patient-reported view on the impact of COVID-19 is important for adequate preparation to ensure undisrupted treatment and allocation of resources.

An Australian-based nomogram predicting nodal positivity for breast cancer in older patients

IntroductionRegional nodal status is one of the most powerful prognosticators in breast cancer. The sentinel lymph node biopsy (SLNB) evaluates the first node in the axillary lymphatic basin theorised to drain the anatomical region of breast cancer. Recent literature has appropriately raised the query of the need for SLNB for breast cancer in older patients (BCOP). Though some early-stage older patients may safely have SLNB omitted, we are potentially missing the under-represented aggressive cancers. No sentinel lymph node metastases nomogram has been developed solely from BCOP data to date. This study aimed to identify older patients with breast cancer at risk for nodal involvement using a nomogram developed from their data alone. MethodsA retrospective analysis of prospectively collected data on BCOP (aged ≥70 years) was performed using the Breast Surgery Quality Audit (BQA). Inclusion criteria were T1-2 invasive breast cancer patients that underwent a SLNB from 1st January 2001 to 31st December 2019. The primary outcome was nodal involvement. Data obtained from the dataset included: age, tumour type, tumour size in millimeters, histological grade, lymphovascular invasion, oestrogen receptor status, progesterone receptor status, HER2 status and referral source. Binary logistic regression was used to develop a nomogram. The model was internally validated by splitting the data set (80% for training and 20% for testing). A receiver operating characteristic curve was developed, with the area under the curve (AUC) and a calibration plot. ResultsThere were 22,313 patients of which 14,856 (66.6%) were symptomatic presentations and 7457 (33.4%) were screen-detected. Invasive tumour type, tumour size, tumour grade, lymphovascular invasion, oestrogen receptors, and referral source indicated a statistically significant effect on predicting a nodal positivity event (Table 1). The AUC was 0.782 (95% CI 0.776–0.789) (Fig. 1a) and demonstrated good calibration (Fig. 1b). The negative predictive value established was 85%. ConclusionWe have developed an Australian sentinel lymph node metastasis nomogram for BCOP using routine histopathological data obtained pre-operatively (Fig. 2). This is the first Australian nomogram, as well as the first nomogram developed solely for BCOP – and maintains a superior AUC compared to other well-established nomograms.

Cross-Sector Intervention Strategies to Target Childhood Food Insecurity in North Carolina

Background Childhood food insecurity increased considerably during the COVID-19 pandemic and is associated with compromised health. Health care systems are increasingly prioritizing food insecurity interventions to improve health, but it is unclear how health systems collaborate with other sectors that are addressing food insecurity. In this study, we aimed to evaluate existing collaborations and explore opportunities for further cross-sector engagement. Methods From December 2020 to March 2021, we conducted semi-structured interviews (N = 34) with informants involved in increasing child food access in North Carolina. Our informants represented different sectors, including community (e.g., food pantry), education (e.g., school lunch program), and government (e.g., Supplemental Nutrition Assistance Program). Rapid qualitative analysis was used to interpret the results and identify themes. Results Informants rarely mentioned the health care sector as a source of referrals or as a collaborator. Barriers limiting access to food insecurity programs were exacerbated by the COVID-19 pandemic, including lack of transportation, stigma deterring use, limited food choice, and burdensome enrollment processes. Stakeholders recommended mitigating barriers through the expansion of food delivery, co-localization of assistance programs in schools and health care settings, increased food choice, and supporting cross-program enrollment mechanisms. Limitations The majority of the stakeholders represented programs from five counties in central North Carolina, with only a few representing statewide initiatives. Conclusions The COVID-19 pandemic both highlighted the fragmented system of food insecurity organizations and accelerated development of cross-sector collaborations to reduce access barriers. Health care systems are siloed from school and community efforts but have the opportunity to leverage ongoing innovative policy initiatives to construct novel cross-sector models. Such models can better link food insecurity screening with community-based solutions to address family-level food access barriers.

A survey of neuropsychological assessment feedback practices among neuropsychologists

Objective Feedback on neuropsychological assessment is a critical part of clinical practice, but there are few empirical papers on neuropsychological feedback practices. We sought to fill this gap in the literature by surveying practicing neuropsychologists in the United States. Questions addressed how they provide verbal and written feedback to patients and referral sources. Survey questions also addressed billing practices and training in the provision of feedback. Methods A survey was developed using Qualtrics XM to survey currently licensed, independently practicing clinical neuropsychologists in the United States about their feedback practices. The survey was completed by 184 individuals. Results Nearly all respondents reported that they provide verbal feedback to patients, most often in-person, within three weeks following testing. Typically, verbal feedback sessions with patients last 45 min. Verbal feedback was provided to referrals by about half of our sample, typically via a brief phone call. Most participants also reported providing written feedback to both the patient and referring provider, most commonly via the written report within three weeks after testing. Regarding billing, most respondents use neuropsychological testing evaluation codes. The COVID-19 pandemic appeared to have had a limited impact on the perceived effectiveness and quality of verbal feedback sessions. Finally, respondents reported that across major stages of professional development, training in the provision of feedback gradually increased but was considered inadequate by many participants. Conclusions Results provide an empirical summary of the “state of current practice” for providing neuropsychological assessment feedback. Further experimental research is needed to develop an evidence-base for effective feedback practices.

Assessing Referrals to a Trauma and Orthopaedic Department: Evaluation of a Traffic Light System for Virtual Fracture Clinic in the Emergency Department and Urgent Care.

Background The Trauma and Orthopaedic (T&O) on-call service receives referrals from the emergency department (ED), general practice (GP) and urgent treatment centres (UTCs)and requests for inpatient reviews.The virtual fracture clinic (VFC) pathway allows ED and UTC clinicians to assess, dischargeand refer when necessary.For VFC, the on-call orthopaedic consultant reviews the cases the next working day and makes an appropriate plan. This pathway consists of a traffic light system, in which practitioners can either safely discharge with written advice (green), refer to the VFC (yellow)or refer to the on-call team (red). Method The aim of this study was to assess how the VFC pathway was being utilised.All referrals to the T&O on-call team over three weeks were evaluated retrospectively.The following referrals were excluded: fractured femur, head injury, trauma calls and back pain pathway.The following data were collected: patient details, diagnosis, referral source, reason for referral, plan, double booking with VFC and appropriateness. Results A total of 191 referrals were analysed. Most referrals are from the ED (51%) and UTC (23%). Of the referrals,39% were deemed to be inappropriate.Of the inappropriate referrals,35% should have been referred directly to the VFC rather than the on-call team. A significant minority (7%) of inappropriate referrals were referred to the on-call team and VFC. Conclusion Education and collaboration are required with the ED and UTC to ensure the proper use of the VFC pathway. Immediate radiograph reporting may also be beneficial.

A cross-sectional study of the impact of the COVID-19 pandemic on an ophthalmology consult service in four Michigan community hospitals.

During the coronavirus disease 2019 (COVID-19) pandemic, private practice, inpatient consult services, and academic residency programs in ophthalmology saw a decrease in patient encounters. This study elucidates how community hospital ophthalmology consult (OC) services were affected during the pandemic. We aim to determine whether there was a change in resident OC volume in a community-based ophthalmology program consult service during the COVID-19 pandemic. Secondary objectives included analyzing the change in the types of diagnoses and the number of patients seen for diabetic retinopathy over the same time. A retrospective cross-sectional study was conducted reviewing the electronic health record (EHR) charts from OCs for the period 2017-2021. Records were categorized by referral source and the nature of OCs (trauma, acute, or chronic); OCs were further grouped by year and weak of referral. An intermonth analysis of weekly OC counts in each category was performed for the average number of consults in February-April 2017-2019 and for February-April 2020. A one-tailed t-test was performed. All t-tests assumed equal variances. Weekly OCs in 2020 revealed no statistically significant differences in overall cases or in acute or chronic cases when the volume before the COVID-19 pandemic was compared to the volume after the onset of the pandemic. However, a statistically significant increase in the average weekly trauma cases was noted when 2020 (an average of 2.7 cases per week) was compared to the weekly average for the same weeks of years 2017- 2019 (0.4; P = 0.016). This statistically significant increase in trauma in 2020 disappeared when comparing weeks 11-17 in 2020 (2.2 cases per week) and the average of 2017-2019 (1.1). This report outlines no significant change in OCs before and after the onset of the pandemic compared to three previous years. There was, however, an increase in trauma consults during the pandemic and an increase in the number (though not the proportion) of diabetic retinopathy (DR+) patients seen by residents. This report uniquely describes no significant changes in the resident volume of patients seen during the COVID-19 global pandemic.

Prediction of a Positive ANA Result for a Rheumatological Diagnosis in an Outpatient Setting

Objective: To study the predictive value of a positive anti-nuclear antibody (ANA) for a rheumatological diagnosis in an outpatient setting. Methods: Individuals who were referred to the rheumatology outpatient clinics because of a positive ANA between July 2014 and June 2015 were retrospectively reviewed. Presenting symptoms in addition to a positive ANA and whether a final rheumatological diagnosis was made were recorded. The positive predictive value of a positive ANA and its titer for a rheumatological diagnosis, with and without accompanying symptoms was evaluated. Results: A total of 230 patients were included (82% women, age 47.7 ± 14.1 years [range 18-84]). Family medicine and the general outpatient clinic were the main sources of referral (32.2%), followed by ophthalmology (13.0%) and otorhinolaryngology (11.7%). A final rheumatological diagnosis was made in 54 (23.5%) patients, with rheumatoid arthritis being the commonest diagnosis (40.7%). In the absence of any associated symptoms, the predictive value of a positive ANA was 0%. The presence of Raynaud’s phenomenon (100%), joint swelling (59.5%), and joint stiffness (48.9%) predicted a better final rheumatological diagnosis along with a positive ANA. ANA titers of 1:80 or less had a low sensitivity for rheumatic diseases. A receiver operating characteristic (ROC) curve analysis showed that an ANA titer of [Formula: see text]1:128 best predicted a rheumatological diagnosis (AUC 0.78 [0.71–0.85]; sensitivity 0.78; specificity 0.64). Conclusions: To improve the prediction for a rheumatological diagnosis, referral for a positive ANA test should be more appropriately done with compatible symptoms.

Facebook’s News Feed Algorithm and the 2020 US Election

Facebook plays a substantial role in shaping exposure to news and information, a role that is particularly significant during democratic elections. This article aims to characterize Facebook’s contribution to news exposure during the 2020 US election. Using internet browsing data from 1.3 million desktop panelists in the United States, we analyze audience flows from Facebook to news and information publishers ( N = 3,247 websites) labeled according to quality (high or low) and geography (non-local or local). We find that Facebook ranked as the fourth largest external referral source to publishers. Our analysis further shows that, among the panel of 1.3 million US adults visiting these publishers via desktop computers, Facebook disproportionately amplified low-quality publishers and extended their audience reach during the study period. We also find evidence that Facebook’s intervention to improve “news ecosystem quality” by tweaking their News Feed algorithm was associated with fewer daily visits to low-quality publishers, but seemed to have a similar effect on other publishers and, according to Facebook-provided data, had little effect on month-over-month traffic. We discuss limitations, open questions about platform impact, and directions for future work.

The Practice of Oral Medicine in South Africa

Oral medicine is a clinical discipline, practiced by periodontists, which concerns itself mostly with the non surgical management of oral mucosal diseases. Many of these diseases are rare and the discipline less well known – making it essential to identify the obstacles this discipline faces. The purpose of this study was to describe the private and academic practice of Oral Medicine. A self-administered, internet-based, questionnaire was distributed to South African periodontists which questioned the clinician’s competency, diseases managed, special investigations performed, referral sources, proportional time and monetary distribution of the discipline, and perceived barriers to the practice. Twenty-six periodontists completed the questionnaire. In comparison to periodontology and implantology, periodontists generally feel less competent, spend less time on, and receive less money from Oral Medicine. Lack of awareness of the speciality (55.6% - 59.3%) was identified as the biggest constraint, with only 11.2% of referrals received from medical doctors. Immune-mediated diseases (29.3%) and benign neoplasms (26.5%) are managed the most, and surgical biopsies (80.2%) are used most regularly to diagnose oral mucosal disease. Oral Medicine is still a lesser-known clinical speciality. Despite the heavy burden of HIV-related oral disease and oral mucosal malignancies, this speciality remains underutilised.

CHRONIC OSTEOMYELITIS: BEWARE OF PRE-REFERRAL CULTURES

Materials & MethodsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures.ResultsWe reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year.60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation.Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation.ConclusionsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires early referral to a specialist Orthoplastic unit. Less than half of organisms cultured pre-operatively reflect the causative organisms cultured intra-operatively with 52% of these infections being polymicrobial.After initial treatment, 8% of patients will require a further combination of extended antibiotic therapy and surgery to eradicate infection.

To confirm your appointment, please press one: Examining demographic and health system interface factors that predict missed appointments in a pediatric outpatient neuropsychology clinic

Objective: Missed patient appointments have a substantial negative impact on patient care, child health and well-being, and clinic functioning. This study aims to identify health system interface and child/family demographic characteristics as potential predictors of appointment attendance in a pediatric outpatient neuropsychology clinic. Method: Pediatric patients (N = 6,976 across 13,362 scheduled appointments) who attended versus missed scheduled appointments at a large, urban assessment clinic were compared on a broad array of factors extracted from the medical record, and the cumulative impact of significant risk factors was examined. Results: In the final multivariate logistic regression model, health system interface factors that significantly predicted more missed appointments included a higher percentage of previous missed appointments within the broader medical center, missing pre-visit intake paperwork, assessment/testing appointment type, and visit timing relative to the COVID-19 pandemic (i.e. more missed appointments prior to the pandemic). Demographic characteristics that significantly predicted more missed appointments in the final model included Medicaid (medical assistance) insurance and greater neighborhood disadvantage per the Area Deprivation Index (ADI). Waitlist length, referral source, season, format (telehealth vs. in-person), need for interpreter, language, and age were not predictive of appointment attendance. Taken together, 7.75% of patients with zero risk factors missed their appointment, while 22.30% of patients with five risk factors missed their appointment. Conclusions: Pediatric neuropsychology clinics have a unique array of factors that impact successful attendance, and identification of these factors can help inform policies, clinic procedures, and strategies to decrease barriers, and thus increase appointment attendance, in similar settings.

Ethnic differences in treatment outcome for children and young people accessing mental health support

Children and Young People (CYP) from minoritized ethnic backgrounds experience structural inequalities in Children and Young People’s Mental Health Settings (CYPMHS). This mixed methods study explores whether CYP’s ethnicity is associated with their treatment outcomes (operationalised as ‘measurable change’) from CYPMHS. A multilevel multi-nominal regression analysis, controlling for age, gender, referral source, presenting difficulty, case closure reason, suggests that CYP from Asian backgrounds (OR = 0.82, CI [0.70, 0.96]) and Mixed-race (odds ratio (OR) = 0.80; 95% CI [0.69, 0.92]) are less likely to report measurable improvement in mental health difficulties compared to White British CYP. Three themes from a thematic analysis of semi-structured interviews with 15 CYP from minoritized ethnic backgrounds focused on views and experiences of ending mental health support are also presented. CYP view personalised support and the right therapist as conducive to good endings and valued a range of outcomes pertaining to empowerment. Experiences of stigma and inequalities may begin to explain the less positive outcomes experienced by Asian and Mixed-race CYP found in the regression analysis. The implications of these findings and future areas of research are suggested.

Analysis of Concomitant Medications Prescribed with Antipsychotics to Patients with Dementia

Introduction: Antipsychotics are still commonly prescribed to patients with dementia, despite the many issues that have been identified. This study aimed to quantify antipsychotic prescription in patients with dementia and the types of concomitant medications prescribed with antipsychotics. Methods: A total of 1,512 outpatients with dementia who visited our department between April 1, 2013 and March 31, 2021, were included in this study. Demographic data, dementia subtypes, and regular medication use at the time of the first outpatient visit were investigated. The association between antipsychotic prescriptions and referral sources, dementia subtypes, antidementia drug use, polypharmacy, and prescription of potentially inappropriate medications (PIMs) was evaluated. Results: The antipsychotic prescription rate for patients with dementia was 11.5%. In a comparison of dementia subtypes, the antipsychotic prescription rate was significantly higher for patients with dementia with Lewy bodies (DLB) than for those with all other dementia subtypes. In terms of concomitant medications, patients taking antidementia drugs, polypharmacy, and PIMs were more likely to receive antipsychotic prescriptions than those who were not taking these medications. Multivariate logistic regression analysis showed that referrals from psychiatric institutions, DLB, N-methyl-<sc>d</sc>-aspartate (NMDA) receptor antagonists, polypharmacy, and benzodiazepine were associated with antipsychotic prescriptions. Conclusions: Referrals from psychiatric institutions, DLB, NMDA receptor antagonist, polypharmacy, and benzodiazepine were associated with antipsychotic prescriptions for patients with dementia. To optimise prescription of antipsychotics, it is necessary to improve cooperation between local and specialised medical institutions for accurate diagnosis, evaluate the effects of concomitant medication administration, and solve the prescribing cascade.