Routine Follow-up Appointments Research Articles

Chronic nonspecific cheilitis associated with tislelizumab treatment in a patient with a history of tongue squamous cell carcinoma: a case report

BackgroundChronic nonspecific cheilitis is a complex condition characterized by persistent lip peeling and discomfort. This case report explores the clinical progression of a patient with history of tongue squamous cell carcinoma and subsequent Tislelizumab treatment, presenting with persistent lip peeling.Case presentationA patient with a history of tongue squamous cell carcinoma (T2N0M0), treated with chemotherapy, surgery, and Tislelizumab, presented with six months of persistent lip peeling. Clinical examination revealed distinct features of chronic nonspecific cheilitis with infectious angular cheilitis (Oral Candidiasis). A tailored treatment plan, emphasizing oral hygiene practices and local treatments with Sodium Bicarbonate, Tacrolimus ointment, and Chlortetracycline ointment. Follow-up visits demonstrated sustained improvement, highlighting the significance of individualized approaches.ConclusionsThis case underscores the importance of recognizing and managing oral manifestations in patients with a history of cancer and immunotherapy. The patient’s response to treatment suggests that a multifaceted approach, combining local therapy with lifestyle modifications, can be effective in managing chronic nonspecific cheilitis associated with immunotherapy. Routine follow-up appointments, guided by personalized medicine principles, contribute to sustained patient well-being.

The impact of premature birth on auditory-visual processes in very preterm schoolchildren

Interactions between stimuli from different sensory modalities and their integration are central to daily life, contributing to improved perception. Being born prematurely and the subsequent hospitalization can have an impact not only on sensory processes, but also on the manner in which information from different senses is combined—i.e., multisensory processes. Very preterm (VPT) children (<32 weeks gestational age) present impaired multisensory processes in early childhood persisting at least through the age of five. However, it remains largely unknown whether and how these consequences persist into later childhood. Here, we evaluated the integrity of auditory-visual multisensory processes in VPT schoolchildren. VPT children (N = 28; aged 8–10 years) received a standardized cognitive assessment and performed a simple detection task at their routine follow-up appointment. The simple detection task involved pressing a button as quickly as possible upon presentation of an auditory, visual, or simultaneous audio-visual stimulus. Compared to full-term (FT) children (N = 23; aged 6–11 years), reaction times of VPT children were generally slower and more variable, regardless of sensory modality. Nonetheless, both groups exhibited multisensory facilitation on mean reaction times and inter-quartile ranges. There was no evidence that standardized cognitive or clinical measures correlated with multisensory gains of VPT children. However, while gains in FT children exceeded predictions based on probability summation and thus forcibly invoked integrative processes, this was not the case for VPT children. Our findings provide evidence of atypical multisensory profiles in VPT children persisting into school-age. These results could help in targeting supportive interventions for this vulnerable population.

UK Cancer and Transition Service (UCATS): Providing tailored cancer care to the gender-diverse community.

e13676 Background: Gender-diverse individuals identify their gender as different to the sex they were assigned at birth. This population experiences health inequity throughout the cancer care pathway partly stemming from limited access to specialist knowledge of gender-affirming care and its intersections with cancer. Notable issues include safety of gender affirming hormones, mutual implications of gender affirming surgeries with cancer surgeries and radiotherapy, and psychological support when dysphoria is exacerbated by a cancer diagnosis. Methods: In response, we established the UK Cancer and Transition Service (UCATS), a national virtual monthly multidisciplinary meeting (MDM) and clinic. Patients are eligible for referral if they identify as gender-diverse and have active or historical malignancy. The service was coproduced with patient and public involvement, including input from a specialist cancer charity for gender and sexual minority people. The service launched in June 2022 and began advertising and requesting patient feedback from January 2023. Results: Between June 2023 and January 2024 UCATS received 20 referrals (10 from gender services, 5 from oncology, and 5 self-referrals). Patients were aged 18 - 68 years. The most common tumour types were breast (n = 6), prostate (n = 5), and gastrointestinal (n = 3). Others were haematological, testicular, gynaecological, and central nervous system. One patient had a familial cancer syndrome, not active cancer. Patients were offered a virtual clinic appointment and MDM discussion. Reasons for referral included safety of gender affirming hormones and surgeries, and expedited gender consultations in view of prognosis, or need for cancer treatments that may affect gender-affirming care. Two patients did not attend, with one sending a nominated family member. Six patients had at least one external clinician dial in for the appointment. Seven patients received follow-up appointments. There were nine completed feedback forms, 4 after first appointment and 5 after follow-up. All patients rated both the communication at the appointment and the information given as 5/5. All patients rated their likelihood to recommend the service as 4 or 5/5. Other points of positive feedback were the detailed outcome letter, speed of appointment, and a sense of advocacy. Next steps include routine follow-up appointments (in response to feedback), wider advertising, increased frequency, and recruitment of nursing support. Conclusions: UCATS successfully caters to an unmet need, coordinating cancer and gender affirming care for gender diverse patients, and providing specialist knowledge and support for patients and care teams.

Breaking down barriers to bariatric care: a qualitative study on how telemedicine could transform patient experiences in a Swiss monocentric setting

ObjectiveTelemedicine is becoming an increasingly feasible option for patients with chronic diseases due to its convenience, cost-effectiveness and ease of access. While there are certain limitations, the benefits can be...

Direct discharge for children with a greenstick or torus fracture of the wrist is a non-inferior satisfactory solution to traditional treatment.

Direct Discharge protocols (DD) can alleviate strain on healthcare systems by reducing routine outpatient follow-up. These protocols include low-complex musculoskeletal injuries, such as isolated greenstick fractures or torus fractures of the wrist in children. While there is consensus on the effectiveness of DD, there is a lack of injury-specific powered studies. This study compares treatment satisfaction between DD and traditional treatment in children with a greenstick fracture or torus fractures of the wrist. Children with isolated torus or greenstick fractures of the distal radius or ulna were eligible for inclusion before (pre-DD cohort) and after (DD cohort) the implementation of DD in four hospitals. Traditionally, patients receive a (soft) cast and minimally one routine outpatient follow-up appointment. With DD, patients are discharged directly from the ED after receiving a brace and information, summarized in a smartphone app and a helpline for questions during recovery. The primary outcome was patient or proxy treatment satisfaction (0 to 10), and a power analysis was performed to assess non-inferiority. Secondary outcomes included complications, functional outcomes measured in Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), primary healthcare utilisation, and secondary healthcare utilisation (follow-up appointments and imaging). In total, 274 consecutive children were included to analyse the primary endpoint. Of these, 160 (58%) were male with a median age of 11years (IQR 8 to 12). Pre-DD and DD treatment satisfaction did not vary statistically significantly for greenstick fractures (p = 0.09) and torus fractures (p = 0.93). No complications were observed. PROMIS UE showed no statistically significant differences before and after implementation of direct discharge protocol for torus (p = 0.99) or greenstick (p = 0.45) fractures. Secondary healthcare utilisation regarding follow-up was significantly lower in the DD-torus cohort compared to the pre-DD torus cohort, with a mean difference (MD) of -1.00 follow-up appointments (95% Confidence Interval (CI) -0.92 to -1.13). Similar results were found in the pre DD-greenstick cohort compared to the pre-DD-greenstick cohort (MD): -1.17 follow-up appointments, 95% CI -1.09 to -1.26). Direct Discharge is non-inferior to traditional treatment in terms of treatment satisfaction for paediatric patients with greenstick or torus fractures of the wrist compared to children treated with rigid immobilisation and routine follow-up. Furthermore, the results demonstrate no complications, comparable functional outcomes, and a statistically significant reduction of secondary healthcare utilisation, making DD a good solution to cope with strained resources for children with an isolated greenstick fracture or torus fracture of the wrist.

The effects of the COVID-19 pandemic on epilepsy patients

Background: Pandemics like the coronavirus disease 2019 (COVID-19) bring along many individual and social problems. We aimed to investigate the impact of the COVID-19 pandemic on anxiety, depression, and quality of life in patients with epilepsy and if seizures worsened because of it. Methods: During their routine outpatient follow-up appointments, the patients were probed using questionnaires prepared in advance and we also administered Beck depression and Hamilton anxiety scales to the patients. Results: The mean age of the patients was 34.9 years and 39.5% of the patients were male. It was asked whether patients had problems accessing medications, hospitals, and doctors or whether they had difficulty receiving tests such as EEG-MRI, and 14.9 % of the patients said they had issues accessing them. About 6.8% of all patients and 5/17 patients with COVID-19 infection reported an increase in seizure frequency of more than 50%. While 49 (30.3%) of 161 patients stated they had insomnia during the pandemic period, 58 (36.02%) patients said they started to experience symptoms of anxiety and depression during the pandemic period. Depression was diagnosed in 71 (44.1%), and anxiety was observed in 34 (21.2%) of 161 patients. Conclusion: As a result of the COVID-19 pandemic and quarantine measures, epilepsy patients have been affected significantly. There was a considerable rise in the number of seizures in a large number of patients, and most of them expressed anxiety, depression symptoms, and insomnia. These rates were observed to be greater in individuals who had refractory epilepsy and a history of COVID infection.

Weight Loss After Laparoscopic Sleeve Gastrectomy in Children and Adolescents.

For children and adolescents with severe obesity, metabolic and bariatric surgery including laparoscopic sleeve gastrectomy (LSG) is increasingly used to facilitate weight loss and reduce associated medical problems. Outcomes of LSG are understudied among patients under age 15years. We sought to examine surgical complications and weight loss outcomes among children and adolescents who underwent LSG. This is a single-center retrospective cohort analysis at a high-volume metropolitan children's hospital in the northeast USA between 2011 and 2021. Weight loss was assessed at routine follow-up appointments for up to 36months postoperatively. There were 12 patients under 13years of age (< 13), 45 from 13 up to 15years of age (13-14), and 57 patients aged 15years or over (≥ 15). Among all patients, 70% were female, 41% were Hispanic, and 18% were non-Hispanic Black. There were no operative mortalities. Two patients had surgical complications requiring reoperation. Follow-up beyond 6months occurred for 62% of patients. Weight loss was evident for each group at all time points, and there was no statistically significant difference among groups at any time point. BMI Z-score reduction at 6months was 1.53 for the < 13 group, 0.89 for the 13-14 group, and 0.86 for the ≥ 15 group and at 36months was 1.79, 1.50, and 1.16, respectively. These results support that LSG is a safe and effective method of achieving weight loss for young adolescents with severe obesity. Strategies to promote postoperative follow-up are needed.

Bringing Opiates Off the Streets and Undertaking Excess Scripts: A novel opiate reclamation and prescription reduction program

BackgroundOpioid diversion and misuse continue to present problems in modern medicine. The “opioid epidemic” has claimed more than 250,000 lives since 1999, with studies pointing to prescription opioids as the culprit for future opiate misuse. Currently, there are no well-described, data-driven processes to educate surgeons on reducing opiate prescribing, informed by personal practice patterns. We designed and implemented a novel opiate reclamation and prescription reduction program for surgeons to reclaim unused medications and decrease prescribing using individual provider data. MethodsWe performed a prospective collection of all unused opiate pain medications for general surgery postoperative patients from July 15, 2020 to January 15, 2021. Patients brought their unused opiates to their routine postoperative follow-up appointment, where they were counted and disposed of in a secure drug take-back bin. Reclaimed opiates were totaled, analyzed, and reported to the providers, who used their individual reclamation rates to refine prescribing habits. ResultsDuring the reclamation period, 168 operations were performed, with a total of 12,970 morphine milligram equivalents of opiate prescribed by 5 physicians. A total of 6,077.5 morphine milligram equivalents (46.9%) were reclaimed, which is the equivalent of 800 5-mg tablets of oxycodone. A review of these data led to a 30.9% decrease in opiate prescriptions by participating surgeons in addition to the reclamation of an additional 3,150 morphine milligram equivalents over the next 6 months. ConclusionContinuous monitoring of the medications returned by patients now continues to inform our providers’ prescribing practices, decreases the amount of opiates in the community, and improves patient safety.

Telehealth in palliative care during the COVID-19 pandemic: A systematic mixed studies review.

The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented disruption to healthcare delivery worldwide. The use of telehealth practices rapidly expanded during the pandemic, while its application in palliative care remains a conflicted issue. The aims of this study were to evaluate users' reports of their satisfaction with telehealth palliative care during COVID-19 and to identify facilitators and barriers to telehealth implementation in palliative care during COVID-19. A systematic search of the literature, including studies between January 2020 and June 2022, was conducted using PubMed, MEDLINE, CINAHL Plus, Embase, and Google Scholar. Empirical studies of telehealth in palliative care during COVID-19 were included. A total of 18 studies were included in the review, of which nine were outpatient consultations, four were family meetings, two were remote volunteering programs, two were inpatient care, and one was a residential care home needs assessment. The satisfaction rates were high (66%-99%) among patients and family members who participated in telehealth consultations, but the satisfaction with family meetings was mixed. Compared with their clients, healthcare professionals were less likely to assess telehealth as satisfactory. The authors identified four barriers and four facilitators. The barriers were technological challenges, lack of nonverbal communication, ethical concerns, and limitations for clinical practice. The facilitators were accessibility and convenience, visual cues, facilitation and training, and family engagement. This systematic mixed studies review suggests that current evidence supports the feasibility of telehealth implementation in palliative care for outpatient consultations and routine follow-up appointments. This review also identified facilitators and barriers to telehealth in palliative care, and the findings can inform the implementation of future palliative care services. Future attention should be paid to the effectiveness of telehealth implementation in palliative care patients.

Tacrolimus-Induced Gingival Hyperplasia.

A 66-year-old man with a history of an orthotopic heart transplant and rheumatoid arthritis presented to the clinic for a routine follow-up appointment. The patient reported swelling in his gums that started after his heart transplant surgery. He underwent gingival laser excision twice in the past, but the swelling recurred. Since his heart transplant surgery, he has taken daily tacrolimus, mycophenolic acid, and prednisone. Gingival hyperplasia (Figure, A) affecting the alignment of the teeth was notable on physical examination. His laboratory workup, including complete blood cell count, was within normal limits. The patient has had no cardiac complications since his surgery and chose to continue taking tacrolimus despite its adverse effect.FIGURE: A and B, Gingival hyperplasia affecting the alignment of the teeth.Tacrolimus is an immunosuppressant used in organ transplants. It has been replacing cyclosporine as it showed it is associated with a lower prevalence and severity of gingival overgrowth. Differential diagnosis: Vitamin C deficiency (scurvy) Gingival plaques Acute myeloid leukemia Peripheral giant cell granuloma Sarcoidosis

Opportunities for implementing a patient-initiated follow-up pathway for patients with psoriasis completing phototherapy.

We performed a retrospective case analysis to identify opportunities to introduce a patient-initiated follow-up (PIFU) pathway for patients with psoriasis completing narrowband ultraviolet B phototherapy at our centre. In total, 42 patients completed phototherapy between January 2016 and August 2018 and outcomes were observed for 36 months after phototherapy cessation. Had a PIFU pathway been in place, 24 routine follow-up appointments could have been saved and 8 nonattendances could have been avoided. Seven patients who were discharged or did not attend follow-up after phototherapy flared within 12 months and could have benefited from PIFU to re-access dermatology care. In total 21 patients (50.0%) experienced a relapse within 36 months of completion of phototherapy, and 18 of these (85.7%) relapsed at 0-12 months. The median time to relapse was 6 months. We conclude a post-phototherapy PIFU pathway could help eliminate unnecessary appointments for patients in remission and improve access for patients who relapse. A 12-month PIFU duration prior to discharge would be sufficient to capture the majority of relapses.

Does the toxicity of endocrine therapy persist into long-term survivorship?: Patient-reported outcome results from a follow-up study beyond a 10-year-survival

BackgroundEndocrine treatment (ET) is a highly effective breast cancer treatment but can distinctly impair breast cancer patients’ quality of life (QOL). In a patient-reported outcome (PROs) study conducted by the authors in 2011, patients reported higher ET-induced symptom levels than known from the registration trials, and was underestimated. Based on these study results, we investigated the long-term sequelae of ET reported by breast cancer survivors (BCS) in a follow-up study conducted 5–10 years after an earlier assessment.MethodsBCS who had participated in the earlier study (n = 436) were approached for study participation either at one of their routine follow-up appointments or via mail; consenting patients were asked to completed the same PRO assessment used in the original study (FACT-B + ES). BCS with relapse/ progressive disease were excluded from the analysis. We compared long-term endocrine symptomatology and overall QOL outcome (i.e. FACT-G and -ES sum score).ResultsA final sample of 268 BCS was included in the analysis. BCS reported a significant improvement of the overall endocrine symptomatology (baseline mean = 59 vs. follow-up mean = 62, p < 0.001), physical (baseline = 23.9 mean vs. follow-up mean = 24.8, p < 0.01) and functional well-being (baseline mean = 21.7 vs. follow-up mean = 22.7, p = 0.013) and overall QOL (mean baseline = 88.3 vs. mean follow-up = 90.9, p = 0.011). However, the prevalence of particular symptoms, well-known to be ET induced, did not change over time such as joint pain (baseline = 45.5% vs. 44.2%, n.s. difference), lack of energy (36.4% vs 33.8%, n.s. difference), weight gain (36.8% vs. 33.9%, n.s. difference) or vaginal dryness (30.2% vs. 33%, n.s. difference) and the proportion reporting lack of interest in sex increased (40.4% vs. 48.7%, p < 0.05).ConclusionPresented results indicate that BCS recover well in terms of overall endocrine symptomatology and quality of life but experience some clinically relevant and unfavorable ET-related long-term effects.

Retrospective Review of Follow-Up Strategies for Patients Receiving Palliative Radiotherapy

<h3>Purpose/Objective(s)</h3> There is no current standard-of-care follow-up strategy for patients who receive palliative radiotherapy (PRT) for bone metastases. Within our institution some providers schedule routine follow-up appointments while others only have follow-up as needed (PRN) following a course of PRT. Our study aims to evaluate whether provider follow up strategy correlates with measurable differences in overall quality of care (QoC). We hypothesize that having a routine follow-up appointment following a course of PRT correlates with improved QoC through improved identification of patients who would benefit from additional treatment. <h3>Materials/Methods</h3> Through retrospective chart review, we identified patients who received PRT for bone metastases at our single institution. Inclusion criteria consisted of age ≥ 18 years at the time of treatment and initial PRT course between July 2020 and June 2021. Patients with bone metastases were identified by ICD-10 codes, radiation course name, and PRT dose. Brain and other non-bone metastases were excluded. Demographic, clinical, and PRT data, and time to retreatment were collected and analyzed via descriptive statistics. Follow-up strategies for PRT patients were identified among 17 radiation oncologists. Differences in rate of retreatment were assessed via Fishers exact test. <h3>Results</h3> A total of 378 unique PRT courses were included in our study. PRT courses were divided into separate cohorts based on having scheduled follow-up post treatment (n=160, 42.3%) vs PRN follow up (n=218, 57.7%). The average patient was 64 years old at the time of treatment in both groups. The most common malignancies were breast (n=80, 21%), prostate (n=78, 20.6%), and lung (n=41, 10.8%) with similar proportions in each group. 191 (50.5%) courses included spinal metastases and 187 (49.5%) included non-spine bone metastases with no significant differences between cohorts. Among the scheduled follow-up cohort, more patients (n=65, 40%) received additional treatment within the following year as either retreatment of the initial site or treatment of new sites of pain when compared to the PRN follow up cohort (n=38, 17%). Patients with scheduled follow up had a shorter median time to retreatment of 103 days vs 142 days in the PRN follow up group. <h3>Conclusion</h3> In our retrospective study, we found that having at least one routine follow up for patients receiving PRT led to higher rates of additional treatment with PRT (40% vs 17%, p<0.01) and a shorter median time to retreatment (103 days vs 142 days). Our study shows potential improvement in the QoC for patients receiving PRT through better identification of patients in need of additional PRT. We acknowledge several limitations to this retrospective analysis including primarily the risk of selection bias which we intend to further explore on subsequent analysis. Our results may serve as a clinical basis to suggest a routine 1–3 month follow up after a course of PRT for bone metastases.

P22 Paraneoplastic diffuse systemic sclerosis in association with ano-rectal tumour

Introduction/BackgroundRheumatic diseases can manifest as a paraneoplastic phenomenon. They can be seen during the course of neoplastic disease, precede the diagnosis, appear simultaneously or occur after the diagnosis of malignancy. Overall, paraneoplastic rheumatic syndromes are rare. It is however important to be aware of this phenomenon as the signs and symptoms of the rheumatic syndrome will usually subside with treatment of the underlying malignant disease. Furthermore, reappearance of symptoms may suggest cancer relapse.Description/Method51 year old woman with no significant past medical history was referred by her General Practicioner with 6-week history of pain and stiffness in hands, arms and legs. There was also associated 4-week history of change in bowel habit (diarrhoea and faecal incontinence). Clinical examination revealed skin thickening proximal to elbows and knees, sclerodactyly, facial telangiectasia as well as tendon friction rubs in lower limbs. There was also a mass palpable on digital rectal examination. Investigations revealed that the patient had new iron deficiency anaemia and mildly raised carcinoembryonic antigen. Anti-RNA polymerase III antibody returned positive. CT of chest, abdomen and pelvis suggested tumour involving the anus and lower rectum with metastatic lymphadenopathy. Those findings were also confirmed on subsequent MRI pelvis and PET CT. She underwent anal biopsy, examination under anaesthesia and formation of loop colostomy. Histopathology results confirmed poorly differentiated squamous carcinoma. Patient was then reviewed by oncology and discussed at multidisciplinary meeting. She was commenced on palliative chemotherapy (paclitaxel and carboplatin). After the first session she became severely anaemic and developed acute renal failure. She passed away approximately three months after initial referral to rheumatology.Discussion/ResultsThis patient was diagnosed with paraneoplastic diffuse systemic sclerosis in association with ano-rectal tumour. Unfortunately at the time of diagnosis the disease was metastatic therefore the only treatment option available was palliative rather than curative. Paraneoplastic rheumatic syndromes are rare. The signs and symptoms are secondary to the presence of malignancy. They may be induced by the substances that are secreted by the tumour or the immune system’s response to the malignant cells. Usually once patient recovers from the neoplastic disease the rheumatic disease signs/symptoms subside. In our patient’s history there were a number of features which raised the possibility of paraneoplastic aetiology. These included: sudden onset and rapid progression of clinical symptoms, late onset of disease (after 50 years of age), family history of cancer (dad had prostate cancer), new iron deficiency anaemia as well as the presence of anti-RNA polymerase III antibodies. This antibody is linked with cancer-associated systemic sclerosis. Patients who are positive have shorter cancer-scleroderma interval. Anti-RNA polymerase III antibody is unique to scleroderma and is not found in cancer patients without scleroderma.Key learning points/ConclusionThe key learning point from this case was not to forget the paraneoplastic aetiology in patients who present with rheumatic syndromes. In particular if the symptoms are of sudden onset or are progressing rapidly/responding poorly to therapy. There is only a small number of cases reported in literature of paraneoplastic systemic sclerosis. Furthermore, the importance of anti-RNA polymerase III antibody testing in scleroderma patients. If positive, it is important to be aware that those patients have >4-fold increased risk of cancer occurring within 2 years of scleroderma onset. It is therefore vital to look for any signs/symptoms during their routine follow-up appointments at rheumatology clinics.

A Retrospective Study: Is Low-Intensity Pulsed Ultrasound (LIPUS) an Effective Alternate Treatment Option for Non-union?

BackgroundThere is ongoing controversy regarding the use of low-intensity pulsed ultrasound (LIPUS) therapy in patients with delayed union or non-union. Exogen (Bioventus, Durham, NC) is a well-known brand of LIPUS, and according to their data, 86% of non-union fractures will heal without the need for surgery. A few independent retrospective studies reported much lower healing rates.MethodA retrospective observational study was performed assessing all the patients who underwent Exogen therapy in a single centre. All patients who were initiated on Exogen after three months with radiographic signs of the delayed union were included in the study. Routine follow-up appointments were organised until clinical and radiological healing could be confirmed. Daily 20-minute Exogen sessions were continued until the fracture was healed or up to a maximum of four months as recommended by the manufacturer.ResultsA total of 37 patients received Exogen therapy from 2012 to 2021, of which only 28 patients met our inclusion criteria and were subsequently analysed. The mean age of the patients was 52.0 (SD ± 20.2) with a male to female ratio of 1.7:1. The average time to healing was 115 (±51.2) days with a success rate of 82.14%. The average interfragmentary gap was 7.5 mm (±5.8) for the fractures that healed whereas the failed treatment was 16.1 mm (±13.8). There was no obvious association between outcomes after Exogen therapy and the patient’s age, sex, time to initiate Exogen, diabetes, and smoking status.ConclusionThis study demonstrated a high success rate of LIPUS therapy for patients with delayed union and non-union. LIPUS represents a safe, non-invasive alternative to revision surgery. An independent risk factor for a potentially poor outcome is an increased interfragmentary gap.

305 Improving Clinic DNA Rates with a Patient Initiated Follow Up Pathway: A Cohort Study

Abstract Introduction A Patient Initiated Follow-Up (PIFU) pathway was implemented in 2019; this enabled patients with specific plastic surgery trauma diagnoses to request a consultant clinic review within 3 months, without a routine follow-up appointment being made. PIFU aims to reduce ‘did not attend' (DNA) rates in line with the Royal College of Surgeons of England Outpatient Clinics Guide. Aim To assess the impact of PIFU on DNA rates of plastic surgery trauma clinics. Method A prospective cohort study of plastic surgery PIFU outpatient clinic DNA rates was undertaken (1st January–31st October 2021) and compared to data held for pre-PIFU pathway DNA rates (1st January–30th June 2018); inclusion dates for 2021 were extended to achieve comparable sample sizes for patient numbers routinely booked into clinics. DNA rates were collected from the hospital clinic database. Data were analysed using IBM®SPSS®. The Kolmogorov-Smirnov test was performed to assess sample population distribution, and the Chi2 test was used to compare categorical data. Results A total of 1702 patients were included in the study. Pre-PIFU, there was an 18% (149/823) DNA rate for patients (31.4 years ± 18.45 years) (mean age ± SD) booked into routine Consultant clinic follow-up. Post-PIFU, there was a 9% (77/879) DNA rate for patients (31.1 years ± 20.77 years) booked into routine Consultant clinic follow-up. This represents a significant reduction in DNA rates by 9% (Chi2=7.49, p&amp;lt;0.01); non-operatively managed hand fracture patients were the most frequent non-attenders. Conclusions The PIFU pathway has significantly reduced trauma clinic DNA rates.

A UK online survey exploring patient perspectives of remote consultations for managing psoriasis and psoriatic arthritis during the SARS-CoV-2 pandemic

ABSTRACT The use of remote consultations via telephone or video can contribute to the management of people with psoriasis and has allowed continuity of patient care throughout the SARS-CoV-2 pandemic, though little is known about the patient experience. The present study aimed to provide insights into the views and experiences of people with psoriasis and psoriatic arthritis on their remote consultations during the SARS-CoV-2 pandemic and develop guidance for patients and healthcare professionals on how to optimise future remote consultations. We conducted a cross-sectional, on-line survey of people with psoriasis and psoriatic arthritis. Data were analysed using descriptive statistics and Thematic Analysis. Overall, 126 people reported experiences of telephone (92%) or video (8%) consultations. Most participants were satisfied with (78%), and were happy for, remote consultations to continue (21%); few were not (5%). Others did not always want remote consultations (39%) and preferred alternating with face-to-face consultations (18%). Some wanted remote care during the pandemic only (17%). Five themes were identified: (1) Advantages of Remote Consultations; (2) Disadvantages of Remote Consultations plus sub-themes (2.1) Practical Issues and (2.2) the Absence of Non-Verbal Cues and Emotions; (3) Serving a Purpose; and (4) A ‘Good’ Remote Consultation; and (5) Advice to Other Patients. Remote consultations form an important part of psoriatic disease management, mainly for routine follow-up appointments in patients with stable disease, and in addition to face-to-face consultations. Additional skills training for clinicians could improve the quality of remote consultations.

Risk factors for cognitive decline in type 2 diabetes mellitus patients in Brazil: a prospective observational study

BackgroundType 2 Diabetes Mellitus (T2DM) patients are twice as likely to develop dementia. The study’s goal was to evaluate cognitive performance and risk factors for cognitive decline in this population.MethodsProspective observational study was conducted with 400 T2DM adults, of whom, during routine baseline and follow-up appointments, had socio-demographic, clinical, and laboratory data collected, and underwent physical examination, screening for depression symptoms (Patient Health Questionaire-9-PHQ-9), and cognitive tests: Mini-Mental State Examination (MMSE), Semantic Verbal Fluency Test, Trail Making Test A/B, and Word Memory Tests. Each cognitive test score was converted to a z-score and its average resulted in a new variable called Global Cognitive z-Score [GCS(z)]. Averages of the cognitive test scores and GCS(z) at both moments were compared by the Student’s T-Test for paired samples. Multivariate binary logistic regression models were built to assess the association of GCS(z) < zero with risk factors for cognitive decline at the baseline and follow-up.ResultsAfter exclusions, 251 patients were eligible, being 56.6% female, mean age of 61.1 (± 9.8) years, 12.6 (± 8.9) years of DM duration, and 7.6 (± 4.2) years of school education. Follow-up had 134 patients reevaluated and took place after a mean of 18.4(± 5.0) months. Eleven (14%) patients with a GCS(z) ≥ 0 at baseline turned into a GCS(z) < 0 at follow-up. There were no significant differences between the means of cognitive test scores and GCS(z) at the two evaluation moments. At the baseline, the multivariate logistic regression model identified five risk factors associated with GCS(z) < zero: age ≥ 65 years, schooling ≤ 6 years, arterial hypertension, depression symptoms, and diabetic retinopathy (DR), with odds ratio (OR) and 95% confidence interval (CI95%) respectively: 5.46 (2.42–12.34); 12.19 (5.62–26.46); 2.55 (0.88–7.39); 3.53 (1.55–8.07) e 2.50 (1.18–5.34). At follow-up, the risk factors for GCS(z) < zero were: schooling ≤ 6 years, DM duration ≥ 10 years, depression symptoms, arterial hypertension, and cardiovascular disease (CVD), OR and CI95% respectively: 10.15 (3.68–28.01); 2.68 (0.96–7.48); 4.92 (1.77–13.70); 7.21 (1.38–35.71) e 5.76 (1.93–17.18).ConclusionsBased on our results, cognitive evaluation and follow-up should be incorporated on the routine of T2DM patients, especially for those with advanced age, low education level, prolonged DM duration, arterial hypertension, depression symptoms, CVD, and DR.

Targeting Patients for Donations: Opening a Door, or Pushing Them through It?

Targeting Patients for Donations: Opening a Door, or Pushing Them through It? Michelle A. Burack I was in the clinic hallway with my patient en route from the waiting room to the exam room for a routine follow-up appointment. I said, “Thank you again, so much, for your donation to the department in my honor.” “Sure, no problem,” my patient replied. “Although I have to say, when I first opened the letter, it was kinda creepy. But I’m so grateful for your excellent care, that I felt like I had to send something.” I stopped in my tracks. “Wait—the hospital sent you something asking for a donation?” I had been practicing at an academic medical center as a neurologist specializing in movement disorders for six years. I was at the awkward Assistant Professor level, feeling confident in the excellence of my clinical skill but still very junior in the power hierarchy. I chose movement disorders as a subspecialty in part because of the long-term relationships we develop with our patients. Conditions like Parkinson’s disease and dystonia are managed, not cured. During training, I looked forward to having the sacred responsibility of following “my” patients over the long course of their disease trajectory. We typically see people every three months for many years. It is a specialty that allows us, in the words of Hippocrates, “to know what sort of person has a disease,” not simply “to know what sort of disease a person has.” Skillful use of available treatments requires attention to nuance: not only the subtle details of how the brain is controlling movement during everyday activities like writing, reaching, and walking, but also aspects of behavior arising from circuits in the brain governing mood, decision-making, and interpersonal relationships. Trust is essential for cultivating the close doctor-patient relationships that I rely on to identify how these diseases and treatments impact domains of brain function that are intimately linked to personhood. After the appointment, I sent an email to the advancement office. “Can you please clarify—are our patients being targeted for donations?” I was informed that legislation passed the previous year made it possible for the advancement office to view the provider’s name and department associated with a patient’s most recent visit, and thereby use that information to send more targeted requests for donations. I was reassured that the reply slips included information on how to opt out of future fundraising requests. [End Page 18] I was distressed that the sacred space of trust that I so carefully cultivated with each patient was being breached by the institution without my knowledge or assent. Nearly a month passed before my outrage had subsided enough for me to write to departmental leadership to share my patient’s feedback about the targeted solicitation feeling “creepy.” I did my best to make the tone of my email constructive: “I thought you might want to know in case it weighs into future discussions regarding this fundraising tactic.” In their replies, the departmental leaders highlighted the “delicate balance” between potential discomfort and making people aware of opportunities to support our mission. They acknowledged my patient’s discomfort but also highlighted a recent $10,000 donation that they attributed to these solicitation letters. I was again reassured that patients were offered the opportunity to “opt out.” The failure to notify faculty of these endeavors was acknowledged; one leader expressed that it would be “TMI” to inform us of every fundraising initiative, whereas another leader proposed sharing copies of future letters with us prior to mailing. I reiterated my personal discomfort with the tactic, acknowledging that the level of discomfort in my case likely stemmed from “the very personal nature of the discussions that transpire over the longitudinal course of caring for people with diseases that threaten their very sense of self.” I shared my opinion that offering patients the opportunity to opt out once they have received a solicitation is too late because “you can’t un-creep people out.” It would be better to allow providers the discretion to opt their patients out based on their knowledge of their patients’ circumstances. I acknowledged that institutional leaders...

292 Patient Centred Care in the Outpatient Department

Abstract Aim The NHS long term care plan recognises the need for a personalised approach to healthcare. Patient initiated follow up (PIFU) is one way in which the NHS can support patients with becoming more autonomous in decisions about their own health. Method Our trust implements PIFU in 2 ways. Firstly, patients considering an elective operation were provided with a clinic letter detailing the treatment options and a PIFU card. They were discharged and asked to return the card if they wished to proceed to surgery, at which point they were added to the waiting list. Secondly, patients discharged from clinic were provided with a card which they returned if they needed to be seen again for the same complaint. Results 95 patients were recruited for the operative pathway. 38 (40%) requested surgical treatment within 6 months. 149 patients were recruited for the clinic pathway, of which 17% returned for the same condition within 6 months. Conclusions This study has shown that 60% of patients choose, after meaningful dialogue and time to reflect, to avoid surgical treatment. In all cases the surgeon would have “added to the waiting list” had a joint decision been made at the end of the consultation. Furthermore, 83% of patients who would ordinarily have had a routine follow-up appointment did not return to clinic. This PIFU system empowers patients to make decisions about treatment. Offering direct access to the operative waiting lists and clinics has multiple benefits: fewer primary care and hospital appointments; reduced waiting times and reduced costs.