Referral For Investigation Research Articles

Targeted liver ultrasound performed by an expert is the pivotal imaging examination for low phospholipid-associated cholelithiasis.

Low phospholipid-associatedcholelithiasis (LPAC) is a clinical syndrome that can be associated with variants in the adenosinetriphosphate-binding cassette subfamily B, member 4 (ABCB4) transporter gene, in a proportion of patients. The diagnosis of LPAC is defined by clinical as well as imaging criteria of intrahepatic hyperechoic foci or microlithiasis and biliary sludge on ultrasound. The aim of the study was to assess the role of imaging in investigating patients presenting with clinical features suggesting a diagnosis of LPAC. Imaging findings in 51 patients with clinical LPAC were retrospectively reviewed. Most patients had been referred with difficult-to-manage biliary pain postcholecystectomy and some with intrahepatic dilated ducts and stones. The diagnosis of LPAC was made on clinical features. The patients were young with symptom onset at median age 24 years and were mainly female (75%). Ultrasound was performed by an expert in 48/51 and magnetic resonance cholangiopancreatography (MRCP) in 47/51 patients. Targeted liver ultrasound found small hyperechoic foci with comet tail artifacts or posterior acoustic shadowing typical of LPAC in 30/48 (63%) of examinations. However, ultrasound examinations performed before referral for investigation did not report these findings. Intrahepatic duct dilatation was seen in 26/51 (51%) of cases. MRCP did not reliably detect microlithiasis. Targeted liver ultrasound performed by an expert aware of the possible diagnosis is the pivotal investigation for patients with clinical features suggesting LPAC. The findings in ultrasound performed before referral suggest LPAC is under-recognized and under-diagnosed.

Heterogeneity in Algorithm-Assisted Decision-Making: A Case Study in Child Abuse Hotline Screening

Algorithmic risk assessment tools are now commonplace in public sector domains such as criminal justice and human services. These tools are intended to aid decision makers in systematically using rich and complex data captured in administrative systems. In this study we investigate sources of heterogeneity in the alignment between worker decisions and algorithmic risk scores in the context of a real world child abuse hotline screening use case. Specifically, we focus on heterogeneity related to worker experience. We find that senior workers are far more likely to screen in referrals for investigation, even after we control for the observed algorithmic risk score and other case characteristics. We also observe that the decisions of less-experienced workers are more closely aligned with algorithmic risk scores than those of senior workers who had decision-making experience prior to the tool being introduced. While screening decisions vary across child race, we do not find evidence of racial differences in the relationship between worker experience and screening decisions. Our findings indicate that it is important for agencies and system designers to consider ways of preserving institutional knowledge when introducing algorithms into high employee turnover settings such as child welfare call screening.

Risk-based stratified primary care for common musculoskeletal pain presentations (STarT MSK): a cluster-randomised, controlled trial.

Risk-based stratified care shows clinical effectiveness and cost-effectiveness versus usual primary care for non-specific low back pain but is untested for other common musculoskeletal disorders. We aimed to test the clinical effectiveness and cost-effectiveness of point-of-care risk stratification (using Keele's STarT MSK Tool and risk-matched treatments) versus usual care for the five most common musculoskeletal presentations (back, neck, knee, shoulder, and multi-site pain). In this cluster-randomised, controlled trial in UK primary care with embedded qualitative and health economic studies we recruited patients from 24 general practices in the West Midlands region of England. Eligible patients were those aged 18 years or older whose general practitioner (GP) confirmed a consultation for a musculoskeletal presentation. General practices that consented to participate via a representative of the cluster were randomly assigned (1:1) to intervention or usual care, using stratified block randomisation. Researchers involved in data collection, outcome data entry, and statistical analysis were masked at both the cluster and individual participant level. Participating patients were told the study was examining GP treatment of common aches and pains and were not aware they were in a randomised trial. GPs in practices allocated to the intervention group were supported to deliver risk-based stratified care using a bespoke computer-based template, including the risk-stratification tool, and risk-matched treatment options for patients at low, medium, or high risk of poor disability or pain outcomes. There were 15 risk-matched treatment options. In the usual care group, patients with musculoskeletal pain consulting their GP received treatment as usual, typically including advice and education, medication, referral for investigations or tests, or referral to other services. The primary outcome was time-averaged pain intensity over 6 months. All analyses were done by intention to treat. The trial is registered with ISRCTN, ISRCTN15366334. Between May 1, 2018, and April 30, 2019, 104 GPs from 24 practices (12 per study group) identified 2494 patients with musculoskeletal pain. 1211 (49%) participants consented to questionnaires (534 in the intervention group and 677 in the usual care group), with 1070 (88%) completing the follow-up questionnaire at 6 months. We found no significant difference in time-averaged pain intensity (mean(SD) mean 4·4 [SD 2·3] in the intervention group vs 4·6 [2·5] in the control group; adjusted mean difference -0·16, 95% CI -0·65 to 0·34) or in standardised function score (mean -0·06 [SD 0·94] in the intervention group vs 0·05 [1·04]; adjusted mean difference -0·07, 95% CI -0·22 to 0·08). No serious adverse events or adverse events were reported. Risk stratification received positive patient and clinician feedback. Risk stratification for patients in primary care with common musculoskeletal presentations did not lead to significant improvements in pain or function, although some aspects of GP decision making were affected, and GP and patients had positive experiences. The costs of risk-based stratified care were similar to usual care, and such a strategy only offers marginal changes in cost-effectiveness outcomes. The clinical implications from this trial are largely inconclusive. National Institute for Health Research.

P032 Are telephone consultations as effective as face-to-face consultations in the follow-up of patients in the Rheumatology Clinic? A service evaluation

Background/AimsThe COVID-19 pandemic forced rheumatology clinics to utilise telephone consultations as a means to limit footfall at hospitals and to protect our vulnerable patients. This was a new mode of service delivery for most rheumatology departments as previously all appointments used to be face-to-face. Although remote consultations were previously being considered as a mode of service delivery, the COVID-19 pandemic has expedited the uptake remote consultations within a very short span of time. There are no systematic studies to compare the effectiveness of remote consultations versus face-to-face consultations although remote consultations are now being widely adopted. Our aim was to assess the effectiveness of telephone consultations compared to face-to-face consultations in the routine review of rheumatology patients.Methods101 face-to-face consultations and 98 telephone consultations were randomly selected from the months of June and August in 2019 and 2020 respectively. The clinic letters were then accessed and the clinic outcomes were noted. The parameters chosen to aid comparison included start of new medication, medication dose changes, referral for investigations, referral to another specialty, referral to MDT, referral for a steroid injection, timescale of subsequent follow up and discharge from services.ResultsThe main results broadly showed similarities in case-mix and several outcomes, including time scale of follow up and intra-articular and intramuscular steroid injections. Fewer patients were started on a new medication following a telephone consultation (14.9% vs 10.2%), more patients had their current medication dose changed (14.9% vs 17.3%) and slightly more patients were referred for investigations (25.7% vs 30.6%). Furthermore, telephone consultations resulted in a lower rate of referrals to MDT (13.9% vs 5.1%) and marginally fewer discharges.ConclusionThe evaluation showed there were clear similarities between the two groups which showed telephone consultations were comparable to face-to-face consultations. Out of the 98 telephone consultations, only 10 were converted to a face-to-face appointment which was lower than many had predicted. However, the drop in referral rates to other specialties may represent that consultants do not feel confident to refer to another team without a comprehensive face-to-face assessment. Telephone consultations, with the back up of face-to-face slots made available for appropriate patients, appear to be an effective means of service delivery and is likely to continue in a scaled down form.Disclosure A. Paul: Other; Sponsorship for educational meetings from UCB, AbbVie, Pfizer, Novartis and Celgene. C. Walker: None. C. McHugh: None.

Faecal calprotectin is not necessarily required as a screen for significant bowel disease in primary care.

NICE recommends measurement of faecal haemoglobin (f-Hb) using faecal immunochemical test (FIT) when colorectal cancer is suspected and calprotectin (f-Cal) in the context of inflammatory bowel disease, though neither is disease specific. During the COVID-19 pandemic, f-Hb has been a requirement prior to referral for endoscopy in England; f-Cal is often performed simultaneously. The aim of this study was to investigate test performance of both tests for significant bowel disease in those patients referred. All adult patients with simultaneous measurements of f-Hb and f-Cal between April 2019 and September 2020 were included. For those referred, outcomes were determined from clinical records. 650 patients with simultaneous samples for f-Hb an f-Cal were managed in Primary Care; 319 patients were referred to hospital; SBD was found in 32 (10.0%) (CRC 5, high risk adenomas 5, IBD 22). At a cut-off of 10μg/g for f-Hb and 200μg/g for f-Cal, the sensitivity, specificity and negative predictive value for diagnosis of SBD were 84.4%, 58.2% and 96.7% and 68.8%, 89.6% and 95.7%, respectively. Performance of both tests would have enabled diagnosis of two more cases of significant, but non-malignant, bowel disease but required over 4% more referrals for investigation. Use of FIT has become established to assist prioritisation of patients for referral from Primary Care. Whilst introduced specifically for CRC, FIT performs well as a rule out for IBD in Primary Care and the use of f-Cal is not required.

Oral mucosal manifestations of systemic disease

Disorders spanning a wide range of body systems may, directly or indirectly, impact upon the orofacial tissues. Specifically, the oral mucosa may be the first, or most severely affected site of systemic disease, posing significant implications for oral health-related quality of life. It is not uncommon for patients to present to their GP with orofacial symptoms, therefore a firm understanding of how systemic disease can manifest in this way is important. This article will discuss oral mucosal presentations of systemic disease, aiming to improve understanding and recognition of these conditions, allowing appropriate referral for investigation, diagnosis and management.

Evaluation of Hospital Referral Notes for Pulmonary Function Tests at Tertiary Care Teaching Hospital in Oman.

ObjectivesThere is substantial increase in referrals for investigations at Sultan Qaboos University Hospital (SQUH). Evaluating the quality of hospital referral notes (RNs) is necessary from diagnostic, patient, and economic perspectives. RNs for pulmonary function tests (PFTs) can be considered as representative of the array of tests performed at SQUH.MethodsThis cross-sectional study evaluated the quality of RNs based on ‘completeness’ for all consecutive patients referred for PFTs at SQUH over six months. Evaluation included documentation of demographic features, RNs date, priority for investigation, referral reason, pulmonary and relevant medical and smoking history for spirometry RNs, and addition of hemoglobin level for full lung functions (Full-LuFs) tests. The proportion of complete RNs was determined and analyzed separately to study association of spirometry and full-LuFs tests with source and reasons for referral.ResultsOnly 644 of 683 RNs were available for analysis. Smoking history was stated in only 3.3% of all RNs; hence, it was excluded from the analysis. RNs were complete only in 12.4% of cases for spirometry and 14.4% for full-LuFs tests. RNs for patients who primarily had pulmonary disease were proportionately incomplete than those for patients with other reasons (p < 0.050). There was no significant association between incompleteness of RNs and referral hospital (SQUH vs. non-SQUH) and SQUH inpatient or outpatient status implying that the overall proportion of completeness of RNs from all concerned referral locations was similar and low in both types of RNs.ConclusionsThere is a need to improve the quality of RNs at SQUH. Referring doctors must be made aware of the importance of completeness of RNs to improve test reporting, patient management and satisfaction, and reduce financial burden on hospital exchequer.

P531 A retrospective audit of the inflammatory bowel disease specialist nurse-led telephone advice service

Abstract Background Inflammatory bowel disease affects more than 300 000 people in the UK. The aims of the audit were to review the current use of a telephone service provided by the IBD specialist nursing team in a DGH with a view to better funding and further development of the facility. Methods The letters generated from each phone call between January and February 2018 were collected and a sample assessed for outcomes directly related to the consultation. Outcomes were subtyped into a change in medical treatment, referral for investigation, referral to another specialist or arrangement of an urgent clinic appointment or hospital admission. Each phone consultation was also assessed as to whether it had avoided an attendance to the GP or hospital via A&amp;E or acute medicine. Results The two-month period yielded 491 phone calls, of which 100 letters were reviewed of which 56 (56%) had ulcerative colitis (UC), 44 (44%) had Crohn’s disease (CD). Male users comprised 36% (vs. 64% females) and the age of callers ranged from 19 to 84 years (median age 44 years). Of the UC patients, 45 patients (80.4%) had been diagnosed over 2 years previously with two (3.6%) having been diagnosed within the preceding 3 months (CD patients 34 (77.3%) &amp;gt;2 years previously and three (6.8%) within the last 3 months). The phone consultations led to a change in medication in 49 cases (49%). Phlebotomy and/or faecal calprotectin testing was requested for 59 patients (59%) following the phone call and a further 17 (17%) were discussed with a consultant, although only 8 (8%) required an IBD nurse-led or gastroenterology consultant-led clinic (six and two patients, respectively). Nine patients (9%) went on to have cross-sectional imaging or ultrasound with contrast and 7 (7%) were referred for endoscopic assessment. The overall complexity of the consultation was assessed by the number of services referred to/requested. Thirty-four patients (34%) merely required reassurance or verbal advice whereas two cases (2%) led to five distinct referrals or investigation requests (one service 33 (33%), two service 20 (20%), three service 9 (9%), four service 3 (3%)). Each phone call was assessed as to whether it had likely avoided attendance elsewhere. This included general practice (25 cases (25%)), accident and emergency (2 (2%)), IBD nurse clinic appointment (41 (41%)) or consultant clinic appointment (6 (6%)). Conclusion (1) Our audit shows that the IBD nurse-led telephone service is extremely demanding, with a large volume of calls. (2) Remote management of patients could be facilitated by the telephone nurse-led hotline advice service leading to a reduction in healthcare costs, avoiding face-to-face consultations and managing patients as per their personalised needs.

Medical care of acute myocardial infarction patients in a resource limiting country, Trinidad: a cross-sectional retrospective study

BackgroundCardiovascular disease remains the most common cause of death. However, effective and timely secondary care contributes to improved quality of life, decreased morbidity and mortality. This study analyzed the medical care of patients in a resource limiting country with a first presentation of acute myocardial infarction (AMI).MethodsA cross-sectional retrospective study was conducted on first time AMI patients admitted between March 1st 2011 and March 31st 2015 to the only tertiary public hospital in a resource limiting country, Trinidad. Relevant data were obtained from all confirmed AMI patients.ResultsData were obtained from 1106 AMI patients who were predominantly male and of Indo Trinidadian descent. Emergency treatment included aspirin (97.2%), clopidogrel (97.2%), heparin (81.3%) and thrombolysis (70.5% of 505 patients with ST elevation MI), but none of the patients had primary angioplasty. Thrombolysis was higher among younger patients and in men. There were no differences in age, sex, and ethnicity in all other treatments. Of the 360 patients with recorded times, 41.1% arrived at the hospital within 4 h. The proportion of patients receiving thrombolysis (door to needle time) within 30 min was 57.5%. In-patient treatment medication included: aspirin (87.1%), clopidogrel (87.2%), beta blockers (76.5%), ACEI (72.9%), heparin (80.6%), and simvastatin (82.5%). Documentation of risk stratification, use of angiogram and surgical intervention, initiation of cardiac rehabilitation (CR), and information on behavioral changes were rare. Electrocardiogram (ECG) and cardiac enzyme tests were universally performed, while echocardiogram was performed in 57.1% of patients and exercise stress test was performed occasionally. Discharge treatment was limited to medication and referrals for investigations. Few patients were given lifestyle and activity advice and referred for CR. The in-hospital death rate was 6.5%. There was a significantly higher relative risk of in-hospital death for non-use of aspirin, clopidogrel, simvastatin, beta blockers, and heparin, but not ACE inhibitors and nitrates.ConclusionsMedication usage was high among AMI patients. However, there was very minimal use of non-pharmacological measures. No differences were found in prescribed medication by age, sex, or ethnicity, with the exception of thrombolysis.

Hospital Attendances and Acute Admissions Preceding a Diagnosis of Occupational Asthma.

Occupational exposures are a common cause of adult-onset asthma; rapid removal from exposure to the causative agent offers the best chance of a good outcome. Despite this, occupational asthma (OA) is widely underdiagnosed. We aimed to see whether chances of diagnosis were missed during acute hospital attendances in the period between symptom onset and the diagnosis of OA. Patients diagnosed with OA at the regional occupational lung disease service in Birmingham between 2007 and 2018 whose home address had a Birmingham postcode were included. Emergency department (ED) attendances and acute admission data were retrieved from acute hospitals in the Birmingham conurbation for the period between symptom onset and diagnosis. OA was diagnosed in 406 patients, 147 having a Birmingham postcode. Thirty-four percent (50/147) had acute hospital attendances to a Birmingham conurbation hospital preceding their diagnosis of OA, including 35 (24%) with respiratory illnesses, which resulted in referral for investigation of possible OA in 2/35. The median delay between symptom onset and diagnosis of OA was 30months (IQR = 13-60) and between first hospital attendance with respiratory illness and diagnosis 12months (IQR = 12-48, range 3-96months) CONCLUSIONS: The chance to reduce the delay in the diagnosis of OA was missed in 33/35 patients admitted or seen in ED with respiratory symptoms in the period between symptom onset and diagnosis of OA. The diagnosis of OA was delayed by a median of 12months by failure to ask about employment and work relationship of symptoms.

Malignant oral melanoma: how to spot it and how it is managed

Abstract: Primary oral melanoma (POM) is a rare malignancy affecting primarily the hard palate and maxillary gingivae. Oral melanoma has a poor prognosis due to the frequent delay in diagnosis, the tendency of the tissues to be invaded locally and the potential to metastasize. This article aims to summarize the key clinical features of different types of oral pigmentation that are likely to be encountered by a general dental practitioner (GDP) and to highlight those that should prompt an urgent referral for investigation. CPD/Clinical Relevance: The aim of this article is to increase awareness of the varying and sometimes atypical features of oral melanoma.

Use of a clinical tool for screening and diagnosis of cutaneous leishmaniasis in Sri Lanka

Cutaneous leishmaniasis (CL) was first detected in Sri Lanka in 1992.Local disease is caused by a genetically different variant of Leishmania donovani. Early case detection and management is the mainstay of L. donovani control. High degree of clinical suspicion is critical but a clinical diagnostic tool is not available for leishmaniasis. Current study described, for the first time, a two-staged clinical algorhythm that facilitates screening of CL in Sri Lanka by primary health care worker in stage 1 and management by medical professional in stage 2.Selected clinical markers of 400 patients suspected of CL were analysed retrospectively with laboratory confirmation of leishmaniasis. Ten clinical markers predicted CL with a over 90% accuracy. Subsets of markers showed high levels of sensitivities (60–97.2%) and/or significant association with positive laboratory results as compared to negative lesions [typical onset (acne-form, painless non-itchy), (P = 0.026), size up to 2 cm (P = 0.046), well-defined edges (P = 0.002), regular edges (P = 0.018), rounded shape (P = 0.030), and lesions at 5–8 months (P = 0.052)]. Five of them (typical onset, number up to 2, small size, rounded edges, and rounded shape) also had > 70% sensitivity levels as compared to laboratory findings. Typical onset had the highest sensitivity of 97% and a PPV of 72%. Lesions at 5–8 months duration having defined edges (P = 0.013, specificity 89.7%, PPV 83.1) or having regular edges (P = 0.006, specificity 86.2%, PPV 82.4%) were also predictive of CL. Most of early laboratory-confirmed ( < 12 months) lesions remained < 3 cm (sensitivity > 67%, PPV > 70%) and had defined edges (sensitivity of 52–71%, specificity 46.7–68.8%), (PPV 75.1–86%). Four clinical markers served as good diagnostic markers in both early ( ≤ 4) and late (>12 months) lesions, viz. typical onset (91.3–98.4%), presence of ≤ 2 lesions (sensitivity 82.6–94.7%), size ≤ 2 cm (66.9–73.7%), and regular edges (68.6–76.3%). Reliability of clinical markers generally declined in chronic lesions. However, small lesions of over 12 months were highly indicative of CL (sensitivity of 66%, specificity 66.7%). None of the single/combination markers, however, were 100% sensitive or specific, highlighting the undeniable usefulness of laboratory confirmation, in diagnosis. Decision-making algorithm used 10 basic clinical features for screening and seven specific clinical markers for clinical handling and referral for investigations.

An audit of echocardiographic referrals for investigation of infective endocarditis at Middlemore Hospital - can we do better?

Background: The referral criteria for screening echocardiography in infective endocarditis (IE) are undefined. The positive predictive value in this scenario is low and overuse of “screening’ echocardiography is potentially costly to the health system. We reviewed the appropriateness of referrals for echocardiography in the investigation of IE and the cost involved. Methods: We retrospectively reviewed all echocardiography referrals for suspected IE at Middlemore Hospital in 2012. Strongly indicated referrals were defined as: treatment for IE, Staphylococcus aureus bacteraemia or candidaemia. Results: A total of 7658 echocardiograms were performed between Jan 2012 and Dec 2012. 232 echocardiograms were performed for suspected IE. 88 (37.9%) referrals were deemed indicated; 33 (38%) patients were treated for IE. For those not treated as IE, 51 (58%) had Staphylocuccus aureus bacteraemia and 4 (4.5%) had candidaemia. Vegetation was identified in 10 (4.3%) patients. The most common alternative diagnoses were sepsis without identified focus (13%), respiratory infection (13%) and septic arthritis (10%). At a cost of NZD215.37 per echocardiogram the excess cost of echocardiograms without strong indication was NZD31013.28. Conclusions: The majority of echocardiograms referrals for suspected IE at our centre did not have strong indication, potentially generating unwarranted costs to the healthcare system. Greater efforts are needed to improve the appropriate use of echocardiography for suspected IE.

Complicated sinusitis in a developing country, a retrospective review

ObjectivesThe aim of our study was to assess the incidence rate, mode of presentation, treatment and outcome measures associated with complicated sinusitis in our developing world setting. Additionally we had hope to identify possible patterns or predisposing factors that may assist us in decreasing the significant morbidity and mortality associated with this serious disease. MethodA retrospective chart review was performed on all patients treated for complicated sinusitis at 3 referral hospitals in Durban South Africa between January 2006 and September 2009. ResultsA total of 220 patients were identified including 138 patients with orbital complications only and 82 with intracranial complications with or without orbital manifestations. We report on the demographics, mode of presentation, microbiology, impact on resources, management and mortality of the study group. The incidence rate was found to be 5.83 per million, the most common risk factors associated with intracranial complications, a persistent headache beyond 1 week and referral from a rural rather than urban area (OR 3.24). We found a high mortality rate of 20.7% in those patients with intracranial complications of their sinusitis. ConclusionsComplicated sinusitis is still far too common in the developing world with young adolescent males most at risk. A high index of suspicion must be maintained in detecting orbital as well as intracranial extension of disease and appropriate referral for investigation and management swift and aggressive in preventing extensive morbidity and mortality.

An Exploration of Child Welfare Investigation Disparity Differences Between States

This article explores state differences in child welfare investigation disparities using the National Child Abuse and Neglect Data System and data from the U.S. Census Bureau. Descriptive statistics and mapped spatial distribution suggest a regional pattern across the country. Bivariate analyses found that investigation disparities were lower in states that were more racially diverse, had more people of any race living in poverty, and responded to more of the community's referrals for investigation. Despite research suggesting that disparities in poverty may contribute to African American disparities in child welfare, this was not a significant correlate in this study.

Abstract 2592: Weakness of ABCD2 Scoring In Transient Ischemic Attack

Introduction: The ABCD2 score is a screening tool used to determine the risk for stroke within the first two days following a TIA. The ABCD2 score is based on 5 parameters: age, blood pressure, clinical features, symptom duration and the presence of diabetes. Each item is scored and added to form a number ranging between 0 and 7. A score of 0-3 predicts a low risk of completed stroke at 2 days (1.0%), 3-4 predicts moderate risk (4.1%) and a score ≥ 5 carries high risk (8.1%). NICE recommends that patients with a score of 4 and above are seen by a stroke physician and investigated within 24 hours of onset. ‘C’, clinical features, is scored out of a maximum of 2 points. Unilateral weakness = 2, speech disturbance = 1, and other presenting symptom = 0. We hypothesised that while the ABCD2 is sensitive for anterior circulation TIA, posterior events will not score in this area, leading to inappropriate risk stratification. Aim: The study aim was to establish if the ABCD2 score is equally effective in stratifying stroke risk in all categories of TIA. Methods: Data was collected retrospectively from TIA clinic referral documentation for all patients presenting over a 7 month period (N=335). Patients scoring ‘0’ for the ‘C’ arm of the ABCD2 score (N=102) were isolated to establish whether TIA was confirmed as the final diagnosis by a stroke physician, and where patients were treated as TIA, the presenting symptom, and vascular territory involved. Results: A ‘C’ score of 0 was present in 103 cases (30%), of which 38 (37%) were diagnosed and managed as TIA . The most common presenting feature in this group was visual disturbance, 20 cases (54%). The majority of these (50%) received a diagnosis of amaurosis fugax, and 25% posterior circulation TIA. The remainder were treated as TIA, but the vascular territory not specified. Facial paraesthesia was described in 5 cases (13%), attributed to carotid artery territory TIA. Ataxia was the presenting feature in 3 patients (8%), attributed to posterior circulation TIA. The remaining 25% had non specific symptoms and the vascular territory not specified on the clinic notes. Conclusion: Our study demonstrates that a significant proportion of confirmed TIA cases do not present with classical symptoms of unilateral weakness and speech disturbance. Isolated visual disturbance appears to be a common presenting feature of a TIA, and amaurosis fugax, a known high risk predictor of subsequent completed stroke is not recognised in the ABCD2 score. Transient balance disturbance and ataxic symptoms are highly suggestive of a posterior circulation event and are again not accounted for. When used in isolation, application of the ABCD2 score in these patients may give an inappropriately low stroke risk prediction, and result in delayed referral for investigation and treatment.

Can Cancer Patients Influence the Pain Agenda in Oncology Outpatient Consultations?

Pain in cancer patients is common, yet it is often inadequately managed. Although poor assessment has been implicated, how patients contribute to this process has not been explicated. This study aims to uncover patients' contributions to discussions about pain during oncology outpatient consultations. Seventy-four medical encounters were observed and audiotaped. Verbatim transcriptions of pain talk were examined using conversational analysis. Thirty-nine of 74 patients talked about pain with 15 different doctors during consultations for follow-up or active treatment. Patients' talk about pain varied consistently according to how pain talk was initiated. In 20 consultations where pain was put on the agenda by patients, they used communication tactics that emphasized their pain experiences, seemingly to attract and maintain their doctors' attention. These tactics appear necessary, as the cancer treatment agenda restricts opportunities for patients to have supportive care needs addressed. On the other hand, in 19 consultations where doctors elicited information about pain, patients used communication tactics that minimized their pain experiences, seemingly to conceal potential disease progression or recurrence, the very focus of these specialist consultations. Where cancer was implicated as the source of pain, chemotherapy or radiotherapy was offered, and where cancer was suspected, referrals for investigations were made. Two of the 20 patients appeared to influence the treatment-focused agenda and were given referrals to pain clinic rather than further cancer therapy as initially recommended.

Lower Rates of Intervention for Symptomatic Carotid Stenosis in Women Than in Men Reflect Differences in Disease Incidence

Although there is little sex difference in the age-specific incidence of transient ischemic attack (TIA) and stroke, substantially more men than women undergo endarterectomy/stenting for symptomatic carotid stenosis. Sexism in referral for investigation or intervention has been proposed as an explanation; however, a lower incidence of carotid disease in women or reluctance to undergo intervention might also be responsible. We determined the sex-specific incidence of symptomatic carotid stenosis and subsequent endarterectomy/stenting from 2002 to 2009 in consecutive patients with TIA or nondisabling ischemic stroke in the Oxford Vascular Study. We studied equivalent data from routine clinical practices in the wider Oxfordshire population. There was no sex difference in age-specific referral rates for carotid imaging in the Oxford Vascular Study (n=616; age-adjusted relative rate [RR] for males vs females=1.08; 95% CI, 0.79 to 1.46; P=0.64). However, rates of 50% to 99% symptomatic carotid stenosis were higher in men (RR=1.89; 95% CI, 1.31 to 2.71; P=0.0005). The same was seen in imaged patients (n=575) in the wider Oxfordshire population (RR=1.82; 95% CI, 1.31 to 2.53; P=0.003) and in pooled data (RR=1.87; 95% CI, 1.32 to 2.64; P=0.0003). Rates of symptomatic carotid occlusion were also higher in men in both populations (RR=3.19; 95% CI, 1.95 to 5.23; P<0.0001). Consequently, although men were more likely to undergo carotid intervention (RR=1.98; 95% CI, 1.43 to 2.75; P<0.0001), the proportion of patients with 50% to 99% symptomatic carotid stenosis who received intervention was similar for men and women (odds ratio=1.13; 95% CI, 0.57 to 2.25; P=0.72). Lower rates of intervention for 50% to 99% symptomatic carotid stenosis in women can be explained by sex differences in population-based incidence. We found no evidence of any investigation or intervention bias.

Multidisciplinary assessment of elderly people with a history of multiple falls reduces the risk of further falls

Does assessment by a multidisciplinary team, or assessment by a community nurse with the ability to refer to other professionals, reduce further falls in recurrent fallers? Cluster-randomised, controlled trial. 18 general practices in the UK. Adults aged at least 65 years, living in the community, who had experienced 2 or more falls in the past year, and who did not present to an emergency department for their most recent fall. Inability to participate for one year, abbreviated mental test score less than 7, and nursing home placement were exclusion criteria. Randomisation of 516 participants allotted 213 to care by the multidisciplinary team (secondary care), 141 to care by the community nurse (primary care), and 162 to usual care. Participants allocated to secondary care attended a multidisciplinary clinic (comprising a doctor, nurse, physiotherapist, and occupational therapist) with referral for investigations, interventions, (including Homecheck), and follow-up if necessary. Participants allocated to primary care were assessed by a community nurse who identified risk factors for falls and could refer to other professionals. Participants in the usual care group were assessed by their usual primary care physicians, who provided management at their own discretion. the primary outcome was the proportion of participants in each group who had at least one fall during the follow-up period of 12 months. Other outcomes were death, move to institutional care, change in Barthel score, change in the timed Get Up and Go score, fall-related fractures, and hospitalisations. Participants lost to follow-up were assumed to have had an adverse outcome. 466 participants contributed data to the primary outcome, with an adverse outcome assumed for a further 39 participants on falls and other dichotomous outcomes. At 12 months, 75% of the secondary care group, 87% of the primary care group, and 84% of the usual care group had fallen. Secondary care prevented significantly more falls than usual care (adjusted odds ratio 0.52, 95% Ci 0.35 to 0.79). the secondary care group also had a significantly more positive Barthel index than the usual care group. the groups did not significantly differ on the other outcomes. The data were also analysed without imputing adverse outcomes for participants who were lost to follow-up. Compared to the usual care group, the secondary care group had significantly fewer falls, fractures, hospitalisations, and deaths. Multidisciplinary assessment of elderly, recurrent fallers reduces the risk of further falls compared to usual care. Assessment of risk factors for falls by a community nurse with the potential to refer to other professionals did not have the same benefit.

Drug therapy in kidney disease

Drug therapy in kidney disease