Routine Outpatient Consultations Research Articles

Effect of point-of-care gastrointestinal ultrasound on decision-making and management in inflammatory bowel disease.

Gastrointestinal ultrasound is increasingly used for point of care assessment of inflammatory bowel disease. To explore the utility of gastrointestinal ultrasound as a point-of-care assessment tool from the perspectives of the clinician and patient. A prospective, observational cohort study was designed utilising routine outpatient consultations. Adult patients with inflammatory bowel disease were allocated to receive gastrointestinal ultrasound or not at the discretion of their treating clinician. Patients completed self-reported session experience questionnaires at study entry, immediately after their consultation, and 4 and 16weeks later. Clinicians reported disease activity status, therapeutic decisions and clinical management. Of 259 participants, mean age 40 (SD: 13) years, 54% male, 73 (28%) underwent ultrasound. Time since diagnosis was 9.2 (8.5) years (ultrasound) and 11.3 (9.2) years (no ultrasound). Immediately after ultrasound, patients who self-reported active disease reported better understanding of all aspects of their disease and disease symptoms were more confident in their ability to make informed decisions about managing their disease and had improved knowledge domain scores compared with the non-ultrasound group (all P<0.05). Ultrasound had no influence over the patients' ability to manage their own healthcare but tended to be associated with transient improvement in medication adherence. After the ultrasound, the clinician's assessment of patient's disease activity changed in 22% (16/73) and management was altered in 56% (41/73) with anti-inflammatory therapy escalated in 33. About 47% (23/49) patients with Crohn's disease had their medication changed in the ultrasound group, compared to only 22% (25/112) in the nonultrasound group (P=0.002). For patients with ulcerative colitis, medications were altered in 68% (15/22) compared to 26% (24/70) in the nonultrasound group (P=0.005) When stratified for disease activity, medication change was more likely in those having ultrasound (P=0.024). Point-of-care gastrointestinal ultrasound has the potential to enhance the clinical management of inflammatory bowel disease by contributing to clinician decision-making and education of patients regarding their disease.

Quality of life assessments in a cohort of Mozambican children with sickle cell disease.

Introductionsickle cell disease (SCD) has significant pediatric morbidity and mortality in sub-Saharan Africa, where access to therapies such as hydroxyurea and opioids is often limited. Poor disease control and Pain management adversely affects the well-being and mental health of affected children. Questionnaires have been utilized in other regions to report the quality of life (QOL) in children with SCD, but assessments from Africa are lacking.Methodschildren age 2-14 years with SCD presenting for routine outpatient consultations at Hospital Central de Maputo from June-August 2017 were offered participation. After informed consent, the Pediatric QOL Inventory (PedsQL) SCD Module was administered to all caregivers and children > 5 years. Responses were scored from 0-100, with higher scores representing better QOL.Resultsa total of 14 children were included, with six (43%), four (29%), two (14%), and two (14%) from the age groups of 2-4, 5-7, 8-12, and 13-14 years, respectively. Mean overall patient QOL was 65.3 and 56.0 in child and caregiver respondents. In patients > 5 years, the difference in mean overall QOL for those on/not on hydroxyurea was 0.6 (66.5-64.9) in child respondents and 15.8 (68.4-52.6) in caregiver respondents. Domains related to worry/emotions and communication scored lower in QOL than Pain-related domains for both patient and caregiver respondents.ConclusionSCD has a negative impact on QOL as reported by this cohort of Mozambican pediatric patients and caregivers, with Pain being less of a concern than emotional and interpersonal issues. A comprehensive, child-focused care approach with robust psychosocial support is needed.

Glioma patients in outpatient care\u2014optimization of psychosocial care in neuro-oncological patients (GLIOPT): Protocol for a cluster randomized controlled trial

BackgroundPatients with high-grade gliomas (HGG) often suffer from high distress and require psychosocial support. However, due to neurological and neurocognitive deficits, adequate assessment of distress and support needs remains challenging in clinical practice. The objective of the present study is to investigate whether a systematic implementation of signaling questions into the routine outpatient consultation will be helpful to bridge this gap.Methods/designThis is a multicenter cluster randomized study with two arms. Randomization is done on a cluster level with 13 hospitals providing regular neuro-oncological outpatient services conducted by neurologists and/or neurosurgeons. The intervention will include an assessment of psychosocial distress of patients in doctor–patient conversation compared to assessment of psychosocial distress via questionnaire (control, standard of care).In total, 616 HGG patients will be enrolled. The outcome will be the number of HGG patients with increased psychosocial distress who receive professional support from psychosocial services.Secondary endpoints are inter alia number of patients reporting psychosocial distress and unmet needs detected correctly by the respective method; quality of life; psychological well-being and burden of the patients before and after doctor–patient consultation; as well as the length of the doctor–patient consultation.DiscussionPatients with HGG are confronted with an oncological diagnosis and at the same time with high symptom burden. This often leads to distress, which is not always adequately recognized and treated. So far, only a limited number of adequate instruments are available to assess HGG patient’s distress. Yet, an adequate care and support network might facilitate the course of the disease and tumor therapies for patients. Our hypothesis is that an assessment conducted directly by attending doctors and in which the doctors talk to patients with HGG will be more effective than an assessment via a questionnaire, leading to better identifying patients in need of support. This may lead to an improvement of health care in these patients. Further, this method might be implemented also in other brain tumor patients (e.g., patients with brain metastases).Trial registrationGerman Clinical Trials Register, DRKS00018079. Registered on 3rd September 2019.

Development, usability and acceptability of an integrated eHealth system for spondyloarthritis in the Netherlands (SpA-Net)

ObjectiveTo develop and test the usability and acceptability of a disease-specific integrated electronic health (eHealth) system for spondyloarthritis (SpA) in the Netherlands (‘SpA-Net’).MethodsSpA-Net was developed in four phases. First, content...

Improving clinical skills to support the emotional and psychological well-being of patients with end-stage renal disease: a qualitative evaluation of two interventions.

BackgroundMany patients with end-stage renal disease (ESRD) need and want improved emotional and psychological support. Explicit attention to patients' emotional issues during consultations can help, yet renal consultants rarely address emotional problems. This qualitative study aimed to evaluate whether two different low-cost interventions could individually enable consultants to talk with patients about their emotional concerns during routine outpatient consultations.MethodOne intervention involved patients using a Patient Issues Sheet to identify two to three issues they would like to talk about in their consultation and the second involved consultants asking patients a direct question about their emotional feelings. Consultants were trained to handle any emotional issues raised. Semi-structured interviews were conducted with five consultants and 36 ESRD patients from two UK renal units. Interviews were transcribed verbatim and analysed using the constant comparative method.ResultsAlthough consultants and patients tended to use the two interventions in different ways, they expressed generally positive views about how helpful the interventions were in promoting discussion of emotional issues. Consultants appreciated the training for facilitating empathetic handling of patients' emotional disclosures and containment of discussion. Most patients who raised emotional concerns were satisfied with their consultant's responses, while others were dissuaded from more explicit discussion by their consultant's concentration on physical considerations.ConclusionsThese qualitative study findings suggest that both interventions are feasible and acceptable and have the potential to help consultants improve emotional and psychological patient care, providing cognitive and behavioural tools to enable discussion of emotional issues during routine outpatient consultations.

Incidence of Parkinson's Disease Related Psychosis in a General Hospital in Singapore

Introduction Quality of life of Parkinson's disease (PD) patients is adversely affected by impairment of physical and psychological functions. Antiparkinson's drugs and disease progression may contribute to the development of secondary symptoms (motor fluctuations, dyskinesias, postural abnormalities, sleep disorders, psychiatric complaints, autonomic disturbances, etc) that may require additional medication to alleviate. Aim Determining local incidence of PD related psychosis will provide foresight into planning of service needs in our local cohort of patients. Objective The aim of this study is to determine the local incidence of psychosis in PD. Methods This is a retrospective cohort study looking at only PD cases diagnosed between January 2006 and December 2007 and recruited into the movement disorder database by the National Neuroscience Institute. The study period is defined as date of diagnosis through to December 2013, where the subjects undergo a variety of scaled assessments conducted during routine outpatient consultations. During the defined study period, a diagnosis of PD related psychosis will be defined as a score of 2 or more on the Thought Disorder subscale of the Unified Parkinson's Disease Rating Scale. Results The proportion of patients in the study population who developed psychotic symptoms during the study period is comparable to existing literature. Conclusion This study allows us to better understand the local incidence of psychosis in PD patients. It provides groundwork for looking at whether regular screening for psychiatric symptoms in this patient cohort would be beneficial in the long term management of PD patients.

Non-verbal communication in meetings of psychiatrists and patients with schizophrenia.

Recent evidence found that patients with schizophrenia display non-verbal behaviour designed to avoid social engagement during the opening moments of their meetings with psychiatrists. This study aimed to replicate, and build on, this finding, assessing the non-verbal behaviour of patients and psychiatrists during meetings, exploring changes over time and its association with patients' symptoms and the quality of the therapeutic relationship. 40-videotaped routine out-patient consultations, involving patients with schizophrenia, were analysed. Non-verbal behaviour of patients and psychiatrists was assessed during three fixed, 2-min intervals using a modified Ethological Coding System for Interviews. Symptoms, satisfaction with communication and the quality of the therapeutic relationship were also measured. Over time, patients' non-verbal behaviour remained stable, whilst psychiatrists' flight behaviour decreased. Patients formed two groups based on their non-verbal profiles, one group (n=25) displaying pro-social behaviour, inviting interaction and a second (n=15) displaying flight behaviour, avoiding interaction. Psychiatrists interacting with pro-social patients displayed more pro-social behaviours (P<0.001). Patients' pro-social profile was associated reduced symptom severity (P<0.05), greater satisfaction with communication (P<0.001) and positive therapeutic relationships (P<0.05). Patients' non-verbal behaviour during routine psychiatric consultations remains unchanged, and is linked to both their psychiatrist's non-verbal behaviour and the quality of the therapeutic relationship.

Uncovering patients’ concerns in routine head and neck oncology follow up clinics: an exploratory study

The Patient Concerns Inventory (PCI) is a tool that enables patients to highlight issues they wish to discuss, and helps to uncover concerns that might otherwise be missed. Previous PCI studies have involved direct observation of a consultation by one assessor using a coding method based rigidly on items listed on the inventory. This pilot study explores the feasibility of developing a standardised method of scoring which can be used to evaluate it. We prospectively recruited 40 disease-free patients attending 42 routine outpatient consultations after treatment for head and neck cancer. Before the consultation they completed the University of Washington quality of life questionnaire and the PCI. Nineteen consultations were audio-recorded and transcribed, and 2 assessors used a thematic framework to analyse the content of the consultation to find the number and types of concerns, the professionals involved, and the clinical outcomes. The assessors were in agreement about 80% (65/81) of the audio-recordings. The mean number of items of concern highlighted on the PCI before consultation was 5.95, median (IQR) 4(3–8) in contrast to 6.47, median (IQR) 6(4–9) for those discussed; for involvement of professionals it was 0.74, median (IQR) 0(0–1) in contrast to 2.63, median (IQR) 3(1–4), respectively. We identified 4 new themes for the working thematic framework, which provided a dynamic, standardised, and comprehensive approach based on the observation and responses of those studied. This approach gave an insight into the way the PCI mediates consultations, and how patients do not always understand the support that specific professionals can provide. Overall, patients were satisfied with the consultations.

A utilização da chupeta e o desenvolvimento sensório motor oral

OBJETIVOS: verificar parâmetros do desenvolvimento sensório motor oral de lactentes no terceiro mês de vida, com e sem o hábito de chupar chupeta, além de identificar a frequência do uso da chupeta entre crianças em aleitamento materno e crianças que iniciaram o desmame. MÉTODOS: estudo observacional com corte transversal, envolvendo 74 bebês que nasceram e estavam realizando acompanhamento no Serviço de Puericultura de uma maternidade da rede pública, Recife-PE. Os dados foram obtidos por meio de entrevista com as mães e observação das crianças. RESULTADOS: as que não utilizavam chupeta apresentaram frequentemente padrão postural global simétrico, melhores respostas aos reflexos orais e língua mais posteriorizada (p=0,034). CONCLUSÃO: constatou-se que as crianças que não utilizaram chupeta apresentaram melhor postura das estruturas orais, como também melhores respostas em relação aos reflexos orais. Nas crianças em aleitamento materno exclusivo foi predominante o não uso da chupeta, havendo associação estatisticamente significante entre o aleitamento materno exclusivo e o não uso da chupeta (p=0,001). Por outro lado, entre as crianças que já haviam iniciado o desmame, o uso da chupeta foi mais frequente.

The sagging rope sign in achondroplasia—different from Perthes’ disease

The sagging rope sign is a radio-opaque line, seen on radiographs of the hips, with Perthes' disease. The main purpose of this study was to determine the incidence, cause and importance of this sign in achondroplasia, and to reveal how it differs from in Perthes' disease. Serial radiograms, along with 2-dimensional and 3-dimensional CT images were studied in 42 achondroplastic patients. Forty-two achondroplastic patients, reported at our institute (for routine outpatient consultation, spine surgeries, deformity corrections, limb-lengthening procedures) were included in this study. There were 26 males and 16 females. The sign was observed bilaterally, in all patients. Evaluation of CT images revealed spherical heads, with presence of circumferential overhang in all hips. This circumferential overhang, seen on 3-D CT scan, corresponded to the sagging rope sign on radiographs. Presence of the sagging rope sign in bilateral hips is a characteristic feature of achondroplasia. It usually appears before epiphyseal closure. Its cause, incidence, and nature differ from Perthes' disease, and its presence does not carry a bad prognosis in achondroplasia.

Clinical applications of renal telemedicine.

In 1994, a telemedicine network was established linking the renal unit at The Queen Elizabeth Hospital to three satellite dialysis centres in South Australia. In the first two and a half years of operation, the telemedicine equipment was used on over 6000 occasions. Interviews were conducted with 18 medical, nursing and allied health staff and dialysis patients. The main finding was that the full range of staff, from surgeons and nephrologists to allied health staff and nurses, were able use the technology successfully for clinical purposes. A second finding was that the technology enabled staff to perform a wide range of clinical procedures, from routine outpatient consultations and monitoring infections to making decisions about retrieval or confirming decisions to operate. A third finding was that telemedicine enabled the renal unit to provide improved services in which teams of staff at the different sites cooperated in ways that were not possible before the telemedicine links became available.