Single-visit Patients Research Articles

Ophthalmology emergency department visits in a Brazilian tertiary hospital over the last 11 years: data analysis.

This study aimed to describe the visits profile to Hospital São Paulo's ophthalmology emergency department, a 24-hour public open-access tertiary-care service in São Paulo, Brazil, that belongs to Federal University of São Paulo, over the last 11 years. A cross-sectional retrospective study was conducted, including all patients (n=634,726) admitted to the ophthalmology emergency department of Hospital São Paulo between January 2009 and December 2019. From 2009 to 2019, the number of patients' presentations increased to 39.2%, with considerable visits variation across the period. The median age was 38 ± 20.4 years. Males represented 53.3%, and single-visit patients represented 53.1%. A total of 79.5% of patients' presentations occurred from 7 am to 5 pm, and 80.8% of patients' presentations occurred during regular weekdays. The most frequent diagnoses were conjunctivitis, blepharitis, keratitis, hordeolum/chalazion, and corneal foreign body. Over the study period, presentations significantly increased in number, with nonurgent visits predominance, and a low number of single-visit patients. Our results demonstrate the ophthalmic visits profile and can lead to changes in the public health system to improve the quality of care and ophthalmology emergency access in São Paulo city.

0530 A Study of Pediatric PAP Compliance in Longitudinal and Single-Visit Patients

Abstract Introduction PAP compliance is difficult to attain and maintain, but important for treatment efficacy in obstructive sleep apnea. This study sought to identify patterns of compliance by age, stratified by gender and device type in patients who followed up only once after treatment initiation (single-visit patients) and those who were seen more than once (longitudinal patients). Methods Charts for approximately 10 months from 10/2018 to 7/2019 were retrospectively reviewed for 1177 patient visits, representing 521 patients with 246 single-visit and 275 longitudinal patients. Some longitudinal patients had visits dating back to 2002. Data analyzed included: age at visit versus compliance measured by percentage of days used and percentage of days used over 4 hours during their compliance period. Data was analyzed for single visit and longitudinal patients stratified by gender and device type. Age was categorized as 0 to 24 months, then years 3.0 to 5.9, 6.0 to 12.9, 13.0 to 18.9 and 19.0 to 21.9. Results Patient demographics: 47.2% single-visit, 52.8% longitudinal; 60% male; Approximately 80% between 6 and 18.9-years-old; 80.8% used CPAP. Statistically significant results:Seen for different age groups among females (p=0.012): Females 19 to 21.9-years-old had 45.8% lower compliance for percentage of days used over 4 hours compared to 3 to 18.9-years-old.Longitudinal patients showed 7.5% and 2.4% better compliance for percentage of days used (p=0.0006) and for days used over 4 hours (p=0.002), respectively, compared to single-visit patients after adjusting for sex and age group. Using a BPAP device was associated with 8.9% better compliance for use over 4 hours (p=0.002) compared to CPAP after adjusting for sex, age and visit groups. Longitudinal patients had 7.7% higher compliance for % days used over 4 hours compared to single visit patients (p=0.0016) after adjusting for sex, age group and device. Conclusion Statistically significant positive factors for compliance were longitudinal patients versus single-visit patients and those using BPAP.Among females, 19 to 21.9-year-olds were least compliant, otherwise no differences between age or gender were identified. Support (If Any)

Dynamics of Hepatitis E Virus (HEV) Antibodies and Development of a Multifactorial Model To Improve the Diagnosis of HEV Infection in Resource-Limited Settings.

Serological markers are important for the diagnosis of hepatitis E virus (HEV) infection. This study aims to compare the diagnostic performance of the anti-HEV IgM and the HEV antigen (Ag) assays and establish a multifactorial model to improve the diagnosis of current HEV infection when HEV RNA detection is not available. A total of 809 serum samples, including 325 anti-HEV IgM-positive and 484 anti-HEV IgM-negative samples, were tested for HEV RNA. The anti-HEV IgM assay had very high sensitivity (99.4%) but moderate accuracy (79.2%) and specificity (74.3%). By retrospective follow-up of 58 patients with sequential samples (n = 143) tested for anti-HEV antibodies, we found anti-HEV IgM remained positive for more than 10 months in some HEV-infected patients, when HEV RNA was already undetectable; thus, decision solely based on anti-HEV IgM may lead to misdiagnosis. In contrast, the HEV Ag assay had very high specificity (100%). However, the detection efficiency of HEV Ag greatly diminished when the HEV RNA level was low or the anti-HEV IgG level was high. By logistic regression, a model integrating anti-HEV IgM, alanine aminotransferase, and HEV Ag was proposed, and the cutoff value was determined based on the testing results of the 143 sequential samples. The model was further evaluated with 67 randomly selected IgM-positive samples from single-visit patients. Overall, the model outperformed the anti-HEV IgM or the HEV Ag assay in the diagnosis of current HEV infection (sensitivity/specificity/accuracy, 89.5%/95.2%/91.9%). The area under the receiver operating characteristics curve of the model was greater than 0.97.

\u201cAnalysis of readmissions to the emergency department among patients presenting with abdominal pain\u201d

BackgroundAbdominal pain is one of the most common complaints among patients admitted to the Emergency Department (ED). Diagnosis and management of abdominal pain may be a challenge and there are patients who require admission to the ED more than once in a short period of time. Our purpose was to assess the incidence of readmissions among patients treated in the ED due to abdominal pain and to investigate the impact of readmission on the further course of treatment.MethodsWe conducted a prospective observational study, which included patients admitted to the ED in one academic, teaching hospital presenting with non-traumatic abdominal pain in a three-month period. Analyzed factors included demographic data, details related to first and subsequent visits in the ED and the course of hospitalization.ResultsOverall, 928 patients were included to the study and 101 (10.88%) patients were admitted to the ED more than once during three-month period. Patients visiting ED repeatedly were older (p = 0.03) and more likely to be hospitalized (p < 0.01) compared to single-visit patients. Patients during their subsequent visits spent more time in the ED (p = 0.01), had greater chance to repeat their appointment (p = 0.04), be admitted to the hospital (p < 0.01) and were more likely diagnosed with cholelithiasis (p = 0.03) compared to patients on their initial visit. If admitted to the surgical department they were also more often qualified for surgical procedure than patients on their first visit (p < 0.01). In a group of patients admitted to the surgical department there were no significant differences in rates of conversion, postoperative complications and mortality between subgroups.ConclusionsReadmissions among patients presenting with abdominal pain are a common phenomenon with prevalence of 10.88%. They are most commonly associated with cholelithiasis and occur more frequently among older patients, which suggests, that elderly require more attention during ED managements.

Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention, Treatment Decisions, and Treatment Outcomes

BackgroundThe United States is in an obesity epidemic. Obesity has multiple common comorbid conditions, including lower extremity arthritis. We sought to examine the course of treatment for a population with body mass index (BMI) ≥40 kg/m2 and osteoarthritis (OA) of the hip or knee. We investigated decision criteria that influenced arthroplasty surgeons to recommend nonoperative management vs total joint arthroplasty (TJA). For those patients who ultimately received TJA, we compared outcomes in this population to those with BMI <40 kg/m2. MethodsThis study retrospectively reviewed 158 new patients with BMI ≥40 kg/m2 and moderate/severe OA of the hip or knee. Demographics, comorbidity profiles, and weight loss were compared between groups that underwent TJA and those that did not. The arthroplasty database was used to identify patients who underwent TJA during 2016-2018 (N = 1473). Comorbidities, readmissions, surgical site infections, and overall complications were compared between those with BMI ≥40 kg/m2 and BMI <40 kg/m2. ResultsAbout 51.3% of new patients with BMI ≥40 kg/m2 and moderate/severe OA did not return for a second clinic visit. Of those who did return, 42.9% eventually underwent surgery. BMI was higher in single visit patients vs those with multiple visits (49.5 vs 46.3 kg/m2, P < .001), no difference in those scheduled on an “as-needed” basis vs a specific return date (P = .18), and did not change significantly during the 2-year follow-up (P = .41). Patients who underwent TJA had a lower mean BMI at presentation than their nonoperative counterparts (44.5 vs 47.6 kg/m2, P < .01) and demonstrated significant weight loss prior to surgery (44.5 vs 42.6 kg/m2, P < .05). When comparing patients with BMI ≥40 kg/m2 vs BMI <40 kg/m2, overall complications were not higher in the BMI ≥40 kg/m2 group, although surgical site infections were higher in those undergoing total hip arthroplasty with BMI ≥40 kg/m2 (0.3% vs 3.1%, P < .05). ConclusionA majority of patients with BMI ≥40 kg/m2 and moderate/advanced OA will be lost to orthopedic follow-up. A relatively lower BMI indicates a greater chance of retention in care, and ultimately surgery, but does not influence surgeons’ recommendations to continue orthopedic management. Patients who persist in seeking treatment, lose significant weight, and exhaust nonoperative alternatives may be suitable for TJA despite a BMI ≥40 kg/m2, with an overall complication rate of 4.3%. However, only 9% of patients at 2-year follow-up achieved BMI <40 kg/m2 and only 20% of surgeries were performed on patients who had achieved this proposed cutoff.

One-stop routing for surgical interventions: a cost-analysis of endoscopic groin repair.

Single-visit (SV) totally extraperitoneal (TEP) inguinal hernia repair is an efficient service without impairment of safety or complication rate. Data on the economic impact of this approach are rare. The aim of this study was to compare the costs between the SV TEP and the regular TEP in an employed healthy population from a hospital and societal point of view. Retrospectively collected hospital costs and prospectively collected societal costs were obtained from patients treated between July 2016 and January 2018. Outcome measures consisted of all documented institutional care, productivity loss and medical consumption. For analysing the hospital costs, a total of 116 SV patients were matched to 116 regular patients. The hospital costs of a mean SV patient were €1148.78 compared to €1242.84 for a regular patient, with a mean difference of €94.06. Prospective analyses of 50 SV patients and 50 regular patients demonstrated higher societal costs for a mean regular patient (€2188.33) compared to a mean SV patient (€1621.44). The mean total cost difference between a SV TEP repair and a regular TEP repair equalled €660.95 corresponding to a 19.3% decrease in costs. This comprehensive cost-analysis showed that in an employed, healthy population, the SV TEP repair outprices the regular TEP repair, with savings of €660.95 per patient, reflecting a 19.3% decrease in costs. This routing is mainly interesting from a societal point of view as the difference is mainly impacted by a decrease in societal costs.

Compliance With Primary Open-angle Glaucoma and Primary Open-angle Glaucoma Suspect Preferred Practice Patterns in a Retail-based Eye Clinic.

To determine the level of adherence to the American Academy of Ophthalmology preferred practice pattern (PPP) guidelines for quality primary open-angle glaucoma (POAG) and POAG suspect (POAGS) care among retail-based optometrists. Patients with a diagnosis of POAG or POAGS who participated in a telemedicine pilot project were included. Patients' charts were evaluated for 15 elements of PPP guidelines for glaucoma care. Results were further stratified by number of follow-up visits and diagnosis. Of 360 identified patients, 10 elements were documented in over 98%. Documentation of the remaining 5 components was as follows: dilated fundus examination 91.1%, central corneal thickness (CCT) 88.6%, visual field 78.9%, gonioscopy 47.5%, and target intraocular pressure (IOP) 15.6%. in total, 32.8% of patients were seen once, whereas the remaining 67.2% had multiple visits. In patients with multiple visits, providers were more likely to document systemic history (100.0% vs. 97.5%; P=0.0346), review of systems (100.0% vs. 97.5%; P=0.0346), gonioscopy (60.0% vs. 22.0%; P<0.001), CCT (94.2% vs. 77.1%; P<0.001), visual field (97.5% vs. 40.7%; P<0.001), and target IOP (22.4% vs. 1.7%; P<0.001) compared with single visit patients. In stratifying results by diagnosis, POAG patients more often received visual field testing (92.7% vs. 68.9%; P<0.001) and had an established target IOP (35.1% vs. 1.4%; P<0.001) compared with POAGS patients. Compliance with PPP guidelines for glaucoma care was very high for most elements but lower for performing dilated fundus examination, CCT, visual field, gonioscopy, and target IOP. This study highlights deficiencies in care likely to hamper the detection of glaucoma progression.

Gender Differences Among Recidivist Trauma Patients

Gender differences among trauma recidivist patients are not well-understood. We hypothesized that males are more likely to be repeatedly involved in the trauma system and have a shorter time to recurrence between repeat episodes of injury compared with females. A retrospective analysis of trauma patients treated at an urban university-based trauma center was performed. Variables including gender, race, insurance status, age, mechanism of injury, outcomes, and injury secondary to domestic violence were compared. Differences were compared using χ(2) tests and log-rank (Mantel-Cox) Kaplan-Meier cumulative event curves. We identified 689 trauma recidivist patients (4.0% of all trauma visits) over a 10-y period. Compared to single-visit patients, recidivist patients were more likely to be male (87% versus 73%), uninsured (78% versus 66%), and have injuries secondary to assaults (54% versus 37%) (P < 0.05). Time from the first to second trauma visit was shorter for females compared with males (23 ± 2.5 versus 30 ± 1.2 mo, P < 0.02). Additionally, female recidivists were more likely to be involved in blunt trauma than were male recidivists (69% versus 43%, P < 0.001). Furthermore, domestic violence was identified in a higher proportion of female recidivist patients than female single-visit patients (3.5% versus 1.6%, P < 0.0003). Contrary to our hypothesis, female recidivist trauma patients have a much shorter time to recurrence for a second traumatic injury than do males. Female recidivists have a high likelihood of assault-associated injuries and domestic violence. Trauma centers should screen for domestic violence among trauma patients to aid in preventing further repeat episodes of injury.

Feasibility of Management of High-Grade Cervical Lesions in a Single Visit: A Randomized Controlled Trial

In this randomized, controlled trial, women from underserved neighborhoods who underwent cervical screening were either managed in the usual fashion and notified of their results with a recommendation for follow up at a later visit or treated in the same visit. Women in the “usual-care” group were dismissed after pelvic examination and Pap smear, and test results were mailed to them. If the smears were abnormal, they were contacted by phone and referred for additional evaluation either within the authors’ clinical system or to their primary care physician with a written copy of their test results. Follow-up information for usual-care patients with abnormal test results was obtained from the patient and from a review of medical records. Participants were told to return for a follow-up examination in 12 months. Women randomized to the “single-visit” group remained after the examination until the results of the cervical smear were known. If the findings were atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous epithelial lesion (LGSIL), the women were referred for additional evaluation as in the usual group. Patients whose smears were positive for high-grade squamous intraepithelial lesion (HGSIL), atypical glandular cells (AGUS), or carcinoma underwent immediate treatment with cervical loop electrosurgical procedure (LEEP). Neither colposcopy nor endocervical excision was performed; however, endometrial biopsies were taken in patients with AGUS. All LEEP patients were asked to return in 2 weeks and at 3 and 12 months for follow up. A total of 3521 women recruited from community health centers in primarily Latino neighborhoods participated in the study. One thousand seven hundred sixteen were randomly assigned to the single-visit group, and 1805 were assigned to the usual group. There was no difference in the rate of abnormal cervical smears (approximately 4% each) or in the rate of high-grade lesions (1%) between the two groups. Fourteen of 16 (88%) women with high-grade lesions in the single-visit group received definitive treatment compared with 10 of 19 (53%) women with a similar diagnosis in the usual-care group (P = .04). One of the two single-visit patients left before her results were known, and one refused treatment. Thirteen of 19 usual-care patients were evaluated with colposcopy within 6 months of the cervical screening, but only 10 were treated as recommended. Treatment and evaluation of low-grade abnormalities were similar for both groups of patients. Two patients, one in the single-visit group and one in the usual-care group, were found to have invasive cancer in the LEEP specimen. Thirty-six percent of patients in each treatment group returned for the follow-up Pap smear at 12 months. Among women with high-grade lesions, more patients in the single-visit group attended the 1-year examination (10 of 16, 63%) than did women in the usual-care group (4 of 19, 21%) (P = .02). The time each woman spent in the clinic was recorded. The mean time from registration to discharge was 2.8 hours for single-visit patients and 1.25 hours for usual-care patients. Responses on a patient questionnaire indicated that 76% of single-visit patients felt that the duration of the first visit was acceptable compared with 89% of those in the usual-care group (P < .001). Ninety-five percent of single-visit women would choose to have a single-visit screening again, and 67% of usual-care patients indicated they would have preferred to wait for results at the same visit.

Feasibility of Management of High-Grade Cervical Lesions in a Single Visit

The incidence of cervical cancer is higher among low-income and minority women who have never undergone a conventional Papanicolaou test or who do not follow up after testing. Screening has been shown to reduce cervical cancer incidence rates. To determine the feasibility and acceptability of immediately treating women with severely abnormal Papanicolaou test results by using a single-visit cervical cancer screening and treatment program and to compare treatment rates and 12-month follow-up rates with those of women who received usual care. Randomized controlled trial conducted among 3521 women aged 18 years or older recruited between January 1999 and April 2002 at US community health centers located in predominantly Latino underserved areas. Women randomized to usual care (n = 1805) were discharged immediately after examination. Women randomized to the single-visit group (n = 1716) remained at the clinic until the results of their conventional Papanicolaou test were available. Large loop electrosurgical excision procedure was performed in single-visit patients with either a diagnosis of a high-grade squamous intraepithelial lesion (HGSIL)/atypical glandular cells of undetermined significance (AGUS) or suspicion of carcinoma. All other patients with abnormal Papanicolaou test results were referred to abnormal cytology clinics or elected to receive follow-up care outside the study's medical system. Treatment rates for HGSIL/AGUS at 6 months, follow-up rates at 6 months for lower-grade lesions, and 1-year follow-up rates for all patients. The rate of abnormal Papanicolaou test results was 4.1%. One percent of results showed high-grade lesions. In the single-visit group, the mean visit time was 2.8 hours and the mean time for delivery and processing of the Papanicolaou tests was 66 minutes. Six months after randomization, 14 (88%) of 16 single-visit and 10 (53%) of 19 usual care patients with HGSIL/AGUS had completed treatment. Fifty percent in the single-visit program and 53% of usual care with less abnormal Papanicolaou tests completed treatment within 6 months. Overall, 36% in each group presented for a follow-up Papanicolaou test 1 year later. Women in the single-visit group with high-grade lesions (10/16; 63%) were significantly more likely to attend follow-up for Papanicolaou tests 12 months later than women with similar lesions in the usual care group (4/19; 21%). For cervical cancer screening, the single-visit program was feasible and the degree of acceptability was high in this underserved population. Single visit programs provide an opportunity to increase the rate of immediate treatment and follow-up of women with severely abnormal Papanicolaou test results. This strategy did not improve follow-up rates for women with less-abnormal results. Trial Registration http://ClinicalTrials.govIdentifier: NCT00237562.

Single-Visit Endodontic Therapy: A Preliminary Clinical Study

A clinical investigation was conducted to compare the incidence and severity of postoperative pain in single-visit and multiple-visit conventional endodontic therapy. Although the single-visit patients seemed to experience more discomfort than did the multiple-visit patients after the first postobturation day, the differences were not statistically significant. When the total number of pain days was considered, there were no significant differences between the two groups. Thus, single-visit endodontic therapy appears at least equal in desirability to multiple-visit therapy from the point of view of painfulness to the patient.

A CLINICAL STUDY OF LICHEN PLANUS

INTRODUCTION In this study of lichen planus the cases considered were clinically typical at some time during observation, all doubtful ones being omitted. In addition to the few that were doubtful, there were probably other instances among the varied lot of dermatological patients seen. As pointing to proof of this is the fact that not always was it possible to determine the true lichen planus character of the eruption at first, and single visit patients are quite common in a dermatological practice. These latter often have their prescriptions refilled many times. In many of the letters received from such patients in answer to queries, the length of time the medicines had been used was stated as months or a year or more. There is another class of patients that, on consulting a specialist, seems to feel a cure should be immediate however long the disease has progressed, and when it