Specialist Recommendation Research Articles

Development of Artificial Neural Network Model for Medical Specialty Recommendation

Timely diagnosis is crucial for a patient’s future care and treatment. However, inadequate medical service or a global pandemic can limit physical contact between patients and healthcare providers. Combining the available healthcare data and artificial intelligence methods might offer solutions that can support both patients and healthcare providers. This study developed one of the artificial intelligence methods, artificial neural network (ANN), the multilayer perceptron (MLP), for medical specialist recommendation systems. The input of the system is symptoms and comorbidities. Meanwhile, the output is the medical specialist. Leave one out cross-validation technique was used. As a result, this study’s F1 score of the model was about 0.84. In conclusion, the ANN system can be an alternative to the medical specialist recommendation system.

Perceptions towards biologic and biosimilar therapy of patients with rheumatic and gastroenterological conditions

BackgroundBiologic and targeted synthetic disease modifying agents (b/tsDMARDs) have broadened the treatment landscape for autoimmune diseases particularly in patients refractory to conventional DMARDs. More recently, the introduction of biosimilars has reduced the price of bDMARDs, potentially improving accessibility. Though efficacy and safety have been described, patient attitudes to b/tsDMARDs are not well-understood. We aim to investigate patients’ beliefs about biologic and biosimilar therapy, and the factors influencing their perceptions.MethodsPatient consumer groups (Arthritis Australia, Crohn’s and Colitis Australia) assisted in advertising an online questionnaire for people with a self-reported diagnosis of inflammatory arthritis (IA) or inflammatory bowel disease (IBD). The questionnaire incorporated the Belief about Medicines Questionnaire (BMQ) and the single-item literacy screener (SILS). Sources and favourability of biologic/biosimilar information were analysed, using the chi-square and a non-parametric trend test for unordered and ordered categorical variables respectively, comparing respondents with IA and IBD.ResultsEight hundred and thirty eight people (686–IA, 144–IBD, 8 both) responded. 658 (79%) used b/tsDMARDs. The BMQ demonstrated high necessity belief (median 4.2) with moderate concerns (median 2.8) about biologics. 95% of respondents obtained medication information from specialists though most used multiple sources (median 4). The most positive resources were specialists and specialist nurses. 73/141 (52%) respondents with IBD obtained information from specialist nurses compared with 202/685 (29%) with IA (p = 0.012). Respondents with limited reading ability on SILS were more likely to discuss information with a general practitioner or pharmacist. Younger respondents and those with higher BMQ concern scores more frequently consulted less reliable sources (e.g. social media). 502 respondents (60%) answered the biosimilar questions. Only 23 (4.6%) reported currently using a biosimilar and 336 (66.9%) were unsure if biosimilars were available in Australia. Specialist recommendation was the most frequent factor that would influence a patient to change from originator to biosimilar (352/495, 71.1%).ConclusionsThere is a high level of trust in specialists’ recommendations about b/tsDMARDs, although most people also utilise additional information sources. Contextual factors influencing resource selection include age, reading ability and degree of concern about medicines. People with IA and IBD have similar attitudes though those with IBD more frequently access specialist nurse advice.

Self-Adaptive Telemedicine Specialist Recommendation Considering Specialist Activity and Patient Feedback.

Purpose: With the rapid development of medical informatization, information overload and asymmetry have become major obstacles that limit patients’ ability to find appropriate telemedicine specialists. Although doctor recommendation methods have been proposed, they fail to address data sparsity and cold-start issues, and electronic medical records (EMRs), patient preferences, potential interest of service providers and the changes over time are largely under-explored. Therefore, this study develops a self-adaptive telemedicine specialist recommendation method that incorporates specialist activity and patient utility feedback from the perspective of privacy protection to fill the research gaps. Methods: First, text vectorization, view similarity and probabilistic topic model are used to construct the patient and specialist feature models based on patients’ EMRs and specialists’ long- and short-term knowledge backgrounds, respectively. Second, the recommended specialist candidate set and recommendation index are obtained based on the similarity between patient features. Then, the specialist long-term knowledge feature model is used to update the newly registered specialist recommendation index and the recommended specialist candidate set to overcome the data sparsity and cold-start issues, and the specialist short-term knowledge feature model is adopted to extend the recommended specialist candidate set at the semantic level. Finally, we introduce the specialists’ activity and patients’ perceived utility feedback mechanism to construct a closed-loop adjusted and optimized specialist recommendation method. Results: An empirical study was conducted integrating EMRs of telemedicine patients from the National Telemedicine Center of China and specialists’ profiles and ratings from an online healthcare platform. The proposed method successfully recommended relevant and active telemedicine specialists to the target patient, and increased the recommended opportunities for newly registered specialists to some extent. Conclusions: The proposed method emphasizes the adaptability and acceptability of the recommended results while ensuring their accuracy and relevance. Specialists’ activity and patients’ perceived utility jointly contribute to the acceptability of recommended results, and the recommendation strategy achieves the organic fusion of the two. Several comparative experiments demonstrate the effectiveness and operability of the hybrid recommendation strategy under the premise of data sparsity and privacy protection, enabling effective matching of patients’ demand and service providers’ capabilities, and providing beneficial insights for data-driven telemedicine services.

P33 Day 3 reviews led by pharmacy technicians—encouraging antimicrobial stewardship

BackgroundA documented 72 h antimicrobial review is a national target that we are expected to achieve at the Leeds Teaching Hospital. Current practice within LTHT provides a pharmacist-led antimicrobial stewardship ward round where IV antimicrobials are reviewed at Day 3 (72 h). Patients prescribed IV antimicrobials are reviewed within 72 h and a decision is made to continue, stop, switch to oral or refer to the outpatient parenteral antimicrobial therapy (OPAT) service. The Healthcare Associated Infection (HCAI) Annual Programme for this year highlights the importance of expanding antimicrobial stewardship within the pharmacy team. This presented an opportunity to develop a new antimicrobial stewardship strategy by leading a virtual pharmacy technician-led antimicrobial stewardship ward round. This allowed for a greater number of patients that were prescribed IV antimicrobials to reviewed and the potential for less patients to remain on broad-spectrum IV antimicrobials for extended durations.ProblemClinicians and pharmacists struggle to undertake this review due to the demands of the daily ward rounds and other reviews that take priority that are needed to ensure patients safety. The electronic prescribing system used within the trust prompts users to undertake Day 3 reviews; however, this is not utilized. This often leads to a greater number of patients remaining on broad-spectrum IV antimicrobials, alongside a lack of justification for remaining on IV antimicrobials despite robust, easily accessible guidelines, education, training and electronic systems.Assessment of problem and analysis of causesFirstly, it is a large teaching hospital that has a variation of different specialities and departments, a lot of patients and fewer people to do the reviews and large turnover of staff and patients. Antimicrobial stewardship is complex, everybody has a role to play in making sure that we use antibiotics appropriately and effectively as IV antibiotics can delay discharge, they are costly, the patients are at risk of line infection, they require IV access and they require more nursing time, so it is necessary to embed antimicrobial stewardship good practice principles throughout the trust and promote that everyone needs to play an active role in this. On identifying the problem, I gained feedback from the pharmacy technicians as to why this review could not be done by them; they reported a lack of knowledge of how to review eligibility of patients for oral switch and with the appropriate training this would be something that they would be happy to do within their daily tasks.MethodsOne pharmacy technician (specializing with infectious disease/pharmacy infection team) was appropriately trained to complete virtual reviews, utilizing an electronic LTHT IV antimicrobial reviewing tool which is available to upload to the patient's electronic records. Patients were identified using a daily antimicrobial prescribing list and filtered for those that had been prescribed IV antimicrobials for 3 days. This allowed for a variety of specialities to be included within the audit. Inclusion criteria: patients aged >16 years, inpatients prescribed IV antibiotics for 72 h. Exclusion criteria: patient aged <16 years, antimicrobial prescribed for the treatment of cystic fibrosis, patients prescribed directed antimicrobial therapy based on an infection specialist recommendation (not empirical treatment), those on oral antibiotics, prophylactic antimicrobials. Data were collected throughout the improvement projected as a baseline audit to understand the impact the intervention made, and results were collated and recorded into an Excel spreadsheet and processed:ResultsA total of 38 patients were included in the audit as having had IV antimicrobial reviews completed. Of these, 28 patients fitted the criteria for a switch from IV to oral antimicrobials and therefore recommendations reflecting this were documented. Advice to de-escalate to oral antimicrobials was followed for 20 patients resulting in a hospital discharge after 24 h. The other 10 patients were advised to continue IV treatment until more clinically stable (advice was followed for 9 patients). Overall recommendations were followed in 76% of cases.ConclusionsOverall, pharmacy technician-led antimicrobial virtual reviews have shown a positive impact on antimicrobial stewardship, by reducing the number of inappropriate IV antimicrobial continued beyond 3 days and ensuring that a greater number of clinical reviews have been documented for the empirical prescribing of IV antimicrobials. This project highlights the potential for a greater number of pharmacy technicians to get involved with IV antimicrobial reviews (once appropriately trained) to complete a small number of reviews weekly, which in turn could provide a reduction of inpatient bed days, decrease harm to patients through the prescribing of antimicrobials, decrease medication costs and improve patient care by facilitating discharge and safeguarding antimicrobials. Additionally, this could help to upskill staff, allowing for greater job satisfaction alongside improved antimicrobial stewardship within the trust.

Design and Deployment of E-Health System Using Machine Learning in the Perspective of Developing Countries

Machine learning is tightening its grasp on many sectors of modern life and medical sector is not an exception. In developing countries like Bangladesh, disease classification process mostly remains manual, time consuming and sometimes erroneous. Designing an E-health system comprised of disease identification model would be a great aid in such circumstances. The automation of identifying the diseases with the help of machine learning will be more accurate and time-saving. In this paper, Decision Tree, Gaussian Naive-Bayes, Random Forest, Logistic Regression, k-NN, MLP, and SVM machine learning techniques are applied for three diseases: Dengue, Diabetes, and Thyroid. MLP for Dengue, Logistic Regression for Diabetes, and Random Forest for Thyroid performed the best with accuracies of 88.3%, 82.5%, and 98.5% respectively. Additionally, a medical specialist recommendation model and a medicine suggestion model are also integrated in the proposed E-Health system.

Study of fuzzy expert system for the diagnosis of various types of cancer

Early exposure of critical diseases is the main necessity for the patients and a difficult errand for the oncologist. In the event that it is distinguished early, it makes the patient bound to live. Lately, the fuzzy rationale has shown up as a dynamical strategy in the acknowledgment of illnesses like various sorts of malignant growths. For the most part, the identification of malignant growths illnesses is taken care of with vagary, mistake, and unclearness yet very much worked by utilizing fuzzy rationale-based models. This paper surveys a few techniques for the early identification of diseases to sum things up. By using fuzzy artificial intelligent Programme, created calculation; patient information alongside master specialist's recommendation, any quiet's infections can be analyzed early which lessen mortality and grimness. This review gives a proposal that a fuzzy approach running smoothly in multiple regions to the diagnosis of cancers.

Specialist recommendation for chemoprevention medications in patients at familial risk of breast cancer: a cross-sectional survey in England

In England, the National Institute for Health and Care Excellence guideline for familial breast cancer recommends chemoprevention for women at high and moderate familial risk of breast cancer. However, prescribing of chemoprevention has not improved since the introduction of the guideline in 2013. The study aims to identify the current practice, in England, of familial cancer specialists offering chemoprevention and recommending prescribing in primary care. This was an anonymized national cross-sectional survey of familial breast cancer risk services in England. Lead clinicians were sent an online survey link. The survey questions included whether chemoprevention was offered/considered for high- and moderate-risk women, when chemoprevention prescribing and recommendation to primary care started, medications prescribed, age groups considered for chemoprevention, and existence of a shared prescribing protocol with primary care. The survey was sent to 115 hospital services; responses from 50 services (43%) were included in the analysis. Of the 40 services offering chemoprevention for high-risk women, 15 (38%) did not prescribe but 31 (78%) recommended prescribing to primary care. Of the 31 services considering chemoprevention for moderate risk, eight (26%) did not prescribe with 26 (84%) recommended prescribing to primary care. Only three services reported having a shared protocol with primary care. Within 3 years of the guidelines, many services recognized the role of chemoprevention for both high and moderate risk with a key role for primary care to initiate prescribing. However, there is still room for improvement.

Gastrostomy uptake in motor neurone disease: a mixed-methods study of patients’ decision making

ObjectivesGastrostomy decision making is a complicated, multifaceted process for people with motor neuron disease (MND). This study explored demographic and disease-related factors that may impact on gastrostomy uptake; and reasons...

Determinants of Vitamin D Supplementation among Individuals with Type 1 Diabetes.

Half of the individuals with type 1 diabetes (T1DM) may present Vitamin D (VD) deficiency. There is little known about factors determining a decision on VD supplementation. The study aimed to determine the factors affecting vitamin D supplementation in people with T1DM. A cross-sectional survey study using the authors’ questionnaire paper and its digital version was performed. The questions involved data on the basic characteristics of the respondent, medical history, VD supplementation status, influence of the social environment, self-education, and the most important personal motivator for VD supplement use. Multivariate logistic regression analysis was performed. We collected a total of n = 184 papers and n = 550 digital complete surveys. From 734 total respondents, 62.0% declared VD supplementation. The main personal rationale for VD supplementation were recommendation of medical specialist 172 (37.8%) and self-education 135 (29.7%). The main reasons for non-supplementation of VD were lack of knowledge about VD 159 (57.0%) and lack of motivation 77 (27.6%). VD supplementation was independently associated with a family doctor (odds ratio (OR), 95% confidence interval (CI): 4.67, 2.32–9.40) or medical specialist recommendation (16.20, 9.57–27.43), and self-education (5.97, 3.90–9.13). Most Polish individuals with T1DM use VD supplements, and the decision is related to physicians’ recommendations and self-education.

Cancer Prevention in Primary Care: Perception of Importance, Recognition of Risk Factors and Prescribing Behaviors

PurposeAcceptability and uptake of cancer preventive interventions is associated with physician recommendation, which is dependent on physician familiarity with available preventive options. The goal of this study is to evaluate cancer prevention perceptions, understanding of breast and ovarian cancer risk factors, and prescribing behaviors of primary care physicians. MethodsWe conducted cross-sectional. Web-based survey of 750 primary care physicians (250 each for obstetrics/gynecology, internal medicine, and family medicine) in the United States. Survey respondents were recruited from an opt-in health care provider panel. ResultsPerception of importance and the practice of recommending general and cancer-specific preventive screenings and interventions significantly differed by provider type. These perceptions and behaviors reflected the demographics of the population that the primary care physicians see within their respective practices. The majority of respondents recognized genetic/hereditary risk factors for breast or ovarian cancer, while epidemiologic or clinical risk factors were less frequently recognized. Prescribing behaviors were related to familiarity with the interventions, with physicians indicating that they more frequently reinforced a specialist's recommendation rather than prescribed a preventive intervention. ConclusionsCancer prevention perceptions, recognition of cancer risk factors, and prescribing behaviors differ among practice types and were related to familiarity with preventive options. Cancer prevention education and risk assessment resources should be more widely available to primary care physicians.

Role of community health worker in a mobile health program for early detection of oral cancer.

The global incidence of oral cancer occurs in low-resource settings. Community-based oral screening is a strategic step toward downstaging oral cancer by early diagnosis. The mobile health (mHealth) program is a technology-based platform, steered with the aim to assess the use of mHealth by community health workers (CHWs) in the identification of oral mucosal lesions. mHealth is a mobile phone-based oral cancer-screening program in a workplace setting. The participants were screened by two CHWs, followed by an assessment by an oral medicine specialist. A mobile phone-based questionnaire that included the risk assessment was distributed among participants. On specialist recommendation an oral surgeon performed biopsy on participants. The diagnosis by onsite specialist that was confirmed by histopathology was considered as gold standard. All individuals received the standard treatment protocol. A remote oral medicine specialist reviewed the uploaded data in Open Medical Record System. Sensitivity, specificity, positive and negative predictive values were calculated. Inter-rater agreement was analyzed with Cohen's kappa coefficient (κ) test, and the diagnostic ability of CHWs, onsite specialist, and remote specialist was illustrated using receiver operating characteristic curve. CHWs identified oral lesions in 405 (11.8%) individuals; the onsite specialist identified oral lesions in 394 (11.4%) individuals; and the remote specialist diagnosed oral lesions in 444 (13%). The inter-rater agreement between the CHW and the onsite specialist showed almost perfect agreement with the κ score of 0.92, and a substantial agreement between CHW and remote specialist showed a score of 0.62. The sensitivity, specificity, positive and negative predictive values of CHWs in the identification of oral lesion were 84.7, 97.6, 84.8, and 97.7%, respectively. The trained CHWs can aid in identifying oral potentially malignant disorders and they can be utilized in oral cancer-screening program mHealth effectively.

Influenza vaccination: Uptake and associations in a cross-sectional study of children with special risk medical conditions

ObjectiveTo determine uptake of influenza vaccination in children with special risk medical conditions (SRMC) and to explore associations with vaccination. DesignCross-sectional study. Setting/participantsParents of children with a SRMC attending either outpatient department clinics or being an inpatient at the Women’s and Children’s Hospital (WCH), Adelaide, Australia from September 2015 to February 2016 were recruited using convenience sampling. MethodsData were collected using a face-to-face survey. Influenza vaccination was verified with providers. Characteristics associated with uptake were explored using univariable and multivariable analyses. ResultsThere were 410 participants with complete data. Confirmed influenza vaccination at least once in the last two years was 50%, annual uptake was 32.8%. 63.9% of parents were aware of the vaccination recommendation and 57.9% had been recommended by a specialist or general practitioner (GP). Characteristics strongly associated with uptake included: receiving a recommendation from a specialist or GP and having a parent receive the influenza vaccine annually. ConclusionsDespite a long standing funded program, influenza vaccination uptake in children with SRMC is suboptimal. Parental vaccination behaviour, along with medical practitioner recommendation, particularly specialist recommendation, appear to be key influences in facilitating vaccination. Potential interventions could target the family rather than just the individual child. Understanding the barriers to recommendation from the perspective of general medical practitioners and specialists who treat these children is needed.

Vitamin D supplementation among Polish medical university students: a cross-sectional study

Background. The data on vitamin D (VD) supplementation rationales and rates among undergraduates of medical universities is limited. We aimed to investigate the rate of students who declare VD supplementation, and factors that influence the decision on VD supplementation. Material and methods. A cross-sectional survey study among medical university students was performed from November 2018 through April 2019. The anonymous questionnaire contained questions about VD supplementation, persons from a student environment, who supplement or recommend VD intake, the most important personal rationale for initiation of or resignation from VD supplementation, the daily dose of VD, the period of supplementation, sex, BMI category, and age. In statistical analysis logistic regression analysis was performed. Results. A total of 595 completed surveys were collected. 303 (50.9%) of the respondents declared VD supplementation. The main personal rationales for VD intake were: knowledge acquired during the studies – 153 (52.1%), knowledge gained beyond the studies – 45 (14.9%), and medical specialist recommendation – 34 (11.2%). The main reasons for resignation from VD supplementation were: lack of motivation – 199 (68.2%), considering the supplementation as a waste of money – 20 (6.8%), and personal belief in little significance of VD for health – 14 (4.8%). VD supplementation was positively associated with studying in the medicine faculty (OR, 95% CI: 1.89, 1.33–2.68), family doctor’s recommendation (1.82, 1.05–3.14), and medical specialist’s recommendation (4.03, 2.15–7.54), and negatively related to friends’ recommendations (0.58, 0.38–0.90). Conclusion. Half of the undergraduates declared VD supplementation. Studying in the medicine faculty and physician’s recommendations were positively associated with VD intake. VD supplementation should be promoted among students.

Factors Related to Migraine Patients' Decisions to Initiate Behavioral Migraine Treatment Following a Headache Specialist's Recommendation: A Prospective Observational Study.

To evaluate the frequency with which migraine patients initiated behavioral migraine treatment following a headache specialist recommendation and the predictors for initiating behavioral migraine treatment. We conducted a prospective cohort study of consecutive patients diagnosed with migraine to examine whether the patients initiated behavioral migraine treatment following a provider recommendation. The primary outcome was scheduling the initial visit for behavioral migraine treatment. Patients who initiated behavioral migraine treatment were compared with those who did not (demographics, migraine characteristics, and locus of control) with analysis of variance and chi-square tests. Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were reached by phone. The mean duration from time of referral to follow-up was 76 (median 76, SD = 45) days. Thirty (56.6%) patients initiated behavioral migraine treatment. There was no difference in initiation of behavioral migraine treatment with regard to sex, age, age of diagnosis, years suffered with headaches, health care utilization visits, Migraine Disability Assessment Screen, and locus of control (P > 0.05). Patients who had previously seen a psychologist for migraine were more likely to initiate behavioral migraine treatment than patients who had not. Time constraints were the most common barrier cited for not initiating behavioral migraine treatment. Less than one-third of eligible patients were referred for behavioral treatment, and only about half initiated behavioral migraine treatment. Future research should further assess patients' decisions regarding behavioral treatment initiation and methods for behavioral treatment delivery to overcome barriers to initiating behavioral migraine treatment.

Les recommandations des néphrologues sont peu suivies par les médecins traitants. L’exemple de la vaccination contre l’hépatite B

The relationship between specialist physician and primary care physician (PCP) has been poorly evaluated in France. We have studied the application of a specialist's recommendation by the PCP. Vaccination against hepatitis B in patients with chronic renal failure was the follow-up marker. After consultation, the nephrologist wrote in his report to the PCP that the vaccination was recommended. At the next nephrological consultation, the patient was asked if the PCP had proposed vaccination. The clinical, biological characteristics and history of the patients were recorded as well as number and location of the PCP consultations. Five nephrology centers recruited 315 patients. In 61.6% (194/315) of the cases, the vaccination was not proposed by the PCP. Only the estimated GFR (lowest in vaccinated patients, 29.5 vs. 34.5mL/min/1.73m2), the delay between the two consultations of the nephrologist (shorter in vaccinated patients, 18.7 vs. 22.9 weeks) and the nephrologist's practice center (17.5 to 52% vaccination rate) are statistically significant in univariate analysis. In multivariate analysis, only the center effect persists. The lack of vaccination was argued by a letter from the PCP in 2 cases (1%). In the absence of a direct questioning of the PCP, the reasons for not following the recommendation remain unexplained. Overall, the recommendation of the nephrologist was little followed. Our study can contribute to the reflection on the shared follow-up of patients suffering from chronic diseases.

Survey of antiobesity drug prescribing for obese children and young people in UK primary care

ObjectivesAntiobesity drug (AOD) prescribing in children and young people (CYP) in primary care is rising with high rates of discontinuation. Little is known about prescribing in this group in terms...

Uptake of Predictive Genetic Testing and Cardiac Evaluation for Children at Risk for an Inherited Arrhythmia or Cardiomyopathy.

Predictive genetic testing in minors should be considered when clinical intervention is available. Children who carry a pathogenic variant for an inherited arrhythmia or cardiomyopathy require regular cardiac screening and may be prescribed medication and/or be told to modify their physical activity. Medical genetics and pediatric cardiology charts were reviewed to identify factors associated with uptake of genetic testing and cardiac evaluation for children at risk for long QT syndrome, hypertrophic cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy. The data collected included genetic diagnosis, clinical symptoms in the carrier parent, number of children under 18years of age, age of children, family history of sudden cardiac arrest/death, uptake of cardiac evaluation and if evaluated, phenotype for each child. We identified 97 at risk children from 58 families found to carry a pathogenic variant for one of these conditions. Sixty six percent of the families pursued genetic testing and 73% underwent cardiac screening when it was recommended. Declining predictive genetic testing was significantly associated with genetic specialist recommendation (p<0.001) and having an asymptomatic carrier father (p=0.006). Cardiac evaluation was significantly associated with uptake of genetic testing (p=0.007). This study provides a greater understanding of factors associated with uptake of genetic testing and cardiac evaluation in children at risk of an inherited arrhythmia or cardiomyopathy. It also identifies a need to educate families about the importance of cardiac evaluation even in the absence of genetic testing.

The prevalence of electrocardiogram abnormalities in professional divers.

The underwater environment presents physiological challenges for the cardiovascular, renal and pulmonary systems. Increases in external hydrostatic pressure reduce the capacity of the venous compartment and cause blood to move toward the lung. The aim of this study was to evaluate retrospectively electrocardiographic (ECG) changes in a cohort of professional divers. Between January 2009 and January 2012, 225 randomly selected professional divers, 204 male (91%) and 21 female (9%) attended our clinic for their biannual diving medical assessment. Their ECG records were evaluated retrospectively. The most common ECG abnormality observed was incomplete right bundle branch block (IRBBB) in 30 divers (13.3%). Eleven divers (4.9%) showed right QRS axis deviation (seven with IRBBB). Six divers had a sinus tachycardia; in four divers there was early repolarization; three divers had ventricular extrasystoles; one diver had ST elevation in lead V3; there was one with sinus arrhythmia and another with T-wave inversion in leads V2, V3 and aVF. These ECG changes were evaluated retrospectively by a cardiologist who made various recommendations for further review including bubble contrast echocardiography for IRBBB. No serious ECG abnormalities were identified, but IRBBB should be further investigated because of its association with persistent (patent) foramen ovale. Rapid cardiological review of ECGs could be achieved using modern communications technology, such as telecardiography, and further clinical investigations directed by specialist recommendation arranged promptly if indicated.

Prevalence of beta-lactam allergy: a retrospective chart review of drug allergy assessment in a predominantly pediatric population.

BackgroundResearch suggests that 90% of patients labeled beta-lactam allergic are able to tolerate penicillins following further assessment. This study aims to define and describe the frequency of true beta-lactam allergy following allergy patient evaluation in a predominantly pediatric population.Methods306 primary care patients referred between January 2010 and June 2015 were assessed for a suspected beta-lactam allergy. Patient demographics, history and test results were extracted from electronic medical records. Testing performed was based on specialist recommendation following review of patient history.Results34% of the study participants had intradermal testing. Oral challenge was given to 96.7% of the sample. 96% of patients with a prior history of beta-lactam allergy were advised that they could re-introduce beta-lactam antibiotics following evaluation.ConclusionsAmong patients with a documented beta-lactam allergy or a recent history of a reaction there is a low rate of ‘true’ beta-lactam allergy. Consistent evaluation of beta-lactam antibiotic allergies can reduce rates of broad spectrum antibiotic prescribing, among other harmful consequences.

Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites

ObjectivesThe increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by...