Specialty Centers Research Articles

The effect of a home exercise program on visio-vestibular function in concussed pediatric patients.

A visio-vestibular home exercise program (VV-HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. The effects of a VV-HEP on improving concussion symptoms and visio-vestibular function are unclear. Determine the effect of VV-HEP on symptoms and visio-vestibular function in concussed pediatric patients. This study included 527 patients [294 female (55.8%); age = 14.4 ± 2.1 years] reporting to a specialty care concussion center within 28 days of injury and for a first follow-up within 60 days of injury. Patients completed the Post-Concussion Symptom Inventory (PCSI) and Visio-Vestibular Examination (VVE). Patients were prescribed the VV-HEP at initial visit, with exercises including saccades, gaze stability, convergence, and balance, and instructed to complete these 1-2 times/day. At follow-up, patients self-reported their VV-HEP progress as (1) has not done, (2) in progress, or (3) completed. Primary outcomes included VV-HEP progress at follow-up, PCSI endorsement and severity, VVE subtests (normal/abnormal), and total VVE score (abnormal = 2 + abnormal subtests). Kruskal-Wallis tests and chi-square were used to determine if concussion symptoms or the proportion of abnormal VVE outcomes, respectively, were associated with VV-HEP status. Post-hoc pairwise comparisons with Bonferonni corrections were used to determine concussion symptom (α = 0.017 a priori) and VVE (α = 0.005 a priori) differences in VV-HEP status. At follow-up, patients who had completed the VV-HEP reported lower symptom endorsement (median = 1, IQR = 0-3) and lower symptom severity (median = 1, IQR = 0-4) relative to patients who had not started the VV-HEP (endorsement median = 7, IQR = 1-13, p < 0.0001; severity median = 15.5, IQR = 2-32.5, p < 0.0001) and those in progress (endorsement median = 8, IQR = 3-14, p < 0.0001; severity median = 15, IQR = 4-30, p < 0.0001). A lower proportion of patients who completed the VV-HEP reported with abnormal vestibular-ocular reflex (22.2%), tandem gait (0%), and total VVE score (22.2%) relative to those who had not started or those in progress (p < 0.005). Our findings indicate that patients who completed the VV-HEP had lower symptom burden and improved visio-vestibular function relative to those who did not start or were in progress. This suggests that a VV-HEP can effectively reduce visio-vestibular dysfunction following concussion and may serve as a means to minimize inequities in access to care.

Exploring the views of Singapore junior doctors on medical curricula for the digital age: A case study.

This study aims to explore the perspectives of medical trainees on the impartation of digital competencies in Singapore's medical school curricula. It also considers how the medical school experience can be strengthened in order to bridge potential gaps in the integration of these competencies in the local curricula. Findings were drawn from individual interviews with 44 junior doctors from Singapore's public healthcare institutions including hospitals and national specialty centers. House officers and residents from different medical and surgical specialties were recruited using purposive sampling. Data was interpreted using qualitative thematic analysis. The doctors were in their first to tenth year of post-graduate training. Thirty of them graduated from the three local medical schools whereas 14 others were trained overseas. Overall, they felt insufficiently prepared to utilize digital technologies in view of their limited exposure to such technologies in medical school. Six key reasons were identified: lack of flexibility and dynamism within the curriculum, dated learning style, limited access to electronic health records, gradual uptake of digital technologies in the healthcare sector, lack of an ecosystem that promotes innovation, and lack of guidance from qualified and available mentors. Equipping medical students with skills relevant to the digital age would benefit from a concerted effort from multiple stakeholders: medical schools, medical educators and innovators, as well as the government. This study bears important implications for countries that seek to bridge the 'transformation gap' brought about by the digital age, which is defined as the sharp divergence between innovations that healthcare providers recognize as important but for which they feel insufficiently prepared.

Abstract P135: Travel Time to Specialty Care and Risk of Death for Children With CHD

Introduction: Children with congenital heart disease (CHD) typically require care from a multi-disciplinary team of providers and treatment at specialized care centers. Although access to specialty care is known to influence patient outcomes, little is known regarding geographic access to care for children with congenital heart disease. This study calculated travel time to specialized care centers and the relationship with mortality for children residing in Colorado. Methods: We analyzed all payer claims data (APCD) from Colorado (CO) from 2012-2019. Travel times were calculated using a network analysis of the road distance weighted by travel speeds from the geographic centroid of every ZIP code in CO to that of the actual specialized care center. Specialty care centers were uniquely identified by their National Provider ID (NPI) and defined by categorizations from the American Medical Association (AMA). Mortality was defined by discharge status. Results: There were 27,344 children with CHD who received specialized care in the study period, accounting for 437,071 total encounters. Of the children with CHD, there were 355 deaths. Children that died had an average of 98 visits per year, while children that survived had an average of 70 visits (p=&lt;0.001). Among the children who lived, 62.8% of their total specialty care visits were &lt;30 minutes away, compared to 59.7% among those who died. CHD who died had a consistently higher proportion of visits that required greater travel to care. Conclusion: Specialized care centers are often located in urban areas and treat patients from diverse geographic areas. There is significant travel burden for children with CHD.

Evaluation the activity of Neuropeptide Y (NPY), Glucagon like peptide-1 and Ghrelin in controlling appetite in obesity in Erbil City

The epidemic of obesity is at previously unheard-of heights. In 2016, it was predicted that 39% and 13% of individuals worldwide were overweight or obese, respectively. Obesity, which is defined as an imbalance between energy intake and expenditure, results from multiple interactions between genetic, environmental, psychological, behavioral, and nutritional variables, making it a difficult condition to study and treat. The present study aimed to approach the understanding of appetite, bodyweight regulation and the causes of obesity through studying gastrointestinal hormones such as (NPY, GLP-1, and ghrelin) hormones and their impact on controlling appetite in obesity. This comparative study included (152) participants (Obese and non-Obese) in the age range (30-66 years), both males and females who visited (The surgical specialty hospital cardiac center, Hawler teaching hospital, and Erbil’s court). A self-administered questionnaire was used for data collection. Fasting serum metabolic parameters and hormones were measured included (S.NPY, S.GLP-1, S.Ghrelin) and (S.Total Cholesterol, S.Triglycerides, S.HDL, S.LDL, and S.VLDL). According to the BMI of participants, there was a significant association (P &lt; 0.001) between NPY, GLP-1 hormones and BMI, and a significant (p = 0.033) association between Ghrelin and BMI. The present study concluded that serum NPY, GLP-1 and Ghrelin hormones significantly impacted controlling appetite in obesity, would be a useful and important marker to evaluation for obesity. And a strong relationship between these hormones and obesity.

An investigational oral plasma kallikrein inhibitor for on-demand treatment of hereditary angioedema: a two-part, randomised, double-blind, placebo-controlled, crossover phase 2 trial

Guidelines recommend effective on-demand therapy for all individuals with hereditary angioedema. We aimed to assess the novel oral plasma kallikrein inhibitor, sebetralstat, which is in development, for on-demand treatment of hereditary angioedema attacks. In this two-part phase 2 trial, individuals with type 1 or 2 hereditary angioedema aged 18 years or older were recruited from 25 sites, consisting of specialty outpatient centres, across nine countries in Europe and the USA. Individuals were eligible if they had experienced at least three hereditary angioedema attacks in the past 93 days, were not on prophylactic therapy, and had access to and the ability to self-administer conventional attack treatment. In part 1 of the trial, participants were given a single 600 mg open-label oral dose of sebetralstat to assess safety, pharmacokinetics, and pharmacodynamics of the dose. Part 2 was a randomised, double-blind, placebo-controlled, two-sequence, two-period (2 × 2) crossover trial; participants were randomly assigned (1:1) to either sequence 1, in which they were given a single dose of 600 mg of sebetralstat to treat the first eligible attack and a second dose of placebo to treat the second eligible attack, or sequence 2, in which they were given placebo to treat the first eligible attack and then 600 mg of sebetralstat to treat the second eligible attack. Participants and investigators were masked to treatment assignment. The primary endpoint was time to use of conventional attack treatment within 12 h of study drug administration, which was assessed in all participants who were randomly assigned to treatment and who received study drug for two attacks during part 2 of the study. Safety was assessed in all participants who received at least one dose of study drug, starting in part 1. This study is registered with ClinicalTrials.gov, NCT04208412, and is completed. Between July 2, 2019, and Dec 8, 2020, 84 individuals were screened and 68 were enrolled in part 1 and received sebetralstat (mean age 38·3 years [SD 13·2], 37 [54%] were female, 31 [46%] were male, 68 [100%] were White). 42 (62%) of 68 participants completed pharmacokinetic assessments. Sebetralstat was rapidly absorbed, with a geometric mean plasma concentration of 501 ng/mL at 15 min. In a subset of participants (n=6), plasma samples obtained from 15 min to 4 h after study drug administration had near-complete protection from ex vivo stimulated generation of plasma kallikrein and cleavage of high-molecular-weight kininogen. In part 2, all 68 participants were randomly assigned to sequence 1 (n=34) or sequence 2 (n=34). 53 (78%) of 68 participants treated two attacks (25 [74%] in the sequence 1 group and 28 [82%] in the sequence 2 group). Time to use of conventional treatment within 12 h of study drug administration was significantly longer with sebetralstat versus placebo (at quartile 1: >12 h [95% CI 9·6 to >12] vs 8·0 h [3·8 to >12]; p=0·0010). There were no serious adverse events or adverse event-related discontinuations. Oral administration of sebetralstat was well tolerated and led to rapid suppression of plasma kallikrein activity, resulting in increased time to use of conventional attack treatment and faster symptom relief versus placebo. Based on these results, a phase 3 trial to evaluate the efficacy and safety of two dose levels of sebetralstat in adolescent and adult participants with hereditary angioedema has been initiated (NCT05259917). KalVista Pharmaceuticals.

Factors affecting the accuracy of amyloidosis identification and referral to a specialty centre

Objective Diagnostic algorithms for amyloidosis have evolved over the past decade, particularly with the incorporation of imaging-based techniques to detect amyloid cardiomyopathy. We sought to identify the key sources of amyloidosis misidentification in the community, which lead to false positive referrals to a tertiary centre. Methods We conducted a retrospective review of all referrals to the Amyloidosis Centre from 2010 to 2021 and identified cases lacking amyloid pathology upon final adjudication after extensive assessment at the centre. Factors for false positive referrals were examined. Results Among 2409 referrals of suspected amyloidosis, 147 (6%) demonstrated an absence of amyloid pathology. This percentage increased over time from 4% in 2010 to 13% in 2021. False positive referrals consisted of more people of colour. The most frequent source of inaccuracy was the erroneous staining of tissue specimens with Congo red, followed by suggestive findings on cardiac imaging. In recent years, misinterpretation of 99mtechnetium- pyrophosphate scintigraphy emerged as a major source of false positive referrals. Conclusion Recognising these potential sources of diagnostic error in the workup of amyloidosis can improve patient care. Referral to a centre of excellence for amyloidosis helps confirm an accurate diagnosis and avoid mistreatment.

Autoimmune Encephalitis Often Is Misdiagnosed, Even at Specialty Centers

Autoimmune Encephalitis Often Is Misdiagnosed, Even at Specialty Centers

SURGICAL TREATMENT OF AN ABNORMAL UPPER LABIAL FRENUM IN PEDIATRIC DENTISTRY

Introduction: The superior labial frenum corresponds to a thin and triangular anatomical structure that has its formation during the third month of intrauterine life, located from the tubercle of the upper lip to the alveolar process. Abnormal insertion of the roof-labial frenulum is usually indicated for surgical removal. If the surgical procedure is not performed, the frenum causes instability, the main problem being the diastema between the incisors, which many times cannot be treated only by orthodontics. The purpose of correction of the upper labial frenum consists of eliminating excess free tissue between the teeth, in addition to the purpose of improving aesthetics. Objective: To describe a case report of surgical treatment of the upper labial frenum performed on a pediatric patient at a Dental Specialties Center. Case report: Female patient, 11 years old, referred by the orthodontist with indication for surgical treatment of the upper labial frenum. On intraoral physical examination, the presence of persistent roof-labial frenum and diastema between the upper central incisors was observed. In view of the data obtained in the anamnesis and physical examination, we opted for the frenotomy technique with the repositioning of the brake. Intraoral antisepsis and facial antisepsis were performed, followed by terminal infiltrative anesthesia in the anterior superior alveolar nerves, bilaterally. Two oblique incisions were made close to the insertion of the roof-labial frenum and then the repositioning of the. Friction movements were performed between the incisors and simple stitches were used for suturing. After two weeks, the patient returned and the presence of tissue remnant was observed, which was removed using the same anesthetic technique and with the aid of Metzenbaum scissors, without the need for a new suture. Conclusion: Surgical treatments for labial frenum present excellent results and should be chosen according to the individual needs of each patient, always evaluating the risks, benefits and advantages and disadvantages.

Are we getting better at cementing femoral stems in total hip arthroplasty? A 5-year institutional trend.

Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or abnormal anatomy. We radiologically evaluated the quality of the femoral cement mantle in patients undergoing THA to examine whether cementation quality improved with increased institutional experience. A retrospective study of 542 primary elective THAs performed using cemented stems from 2016 to 2021 at a high-volume orthopedic specialty center was conducted. Immediate post-operative anterior-posterior (AP) and lateral radiographs were evaluated to assess cement mantle quality based on the Barrack classification. Cement mantles were deemed satisfactory (Barrack A and B) or unsatisfactory (Barrack C and D). Regression was performed to identify predictors of unsatisfactory cementation quality. The annual cemented primary THA volume increased throughout the study period from 14 cases in 2016 to 201 cases in 2021. Overall, the majority of cement mantles were deemed satisfactory; 91.7% on AP radiographs and 91.0% on lateral radiographs. Satisfactory cementation on AP radiograph achievement rates improved during the study period, which coincided with greater annual volume (p < 0.001). No association was found between posterior and direct anterior surgical approaches and satisfactory cementation quality on both AP and lateral radiographs. Majority of femoral stems had satisfactory cementation quality. Higher institutional annual cemented THA volume was associated with improved cementation quality. Residency and fellowship training programs should place greater emphasis on the importance of femoral stem cementation for appropriately indicated patients. III, retrospective cohort study.

Breast Cancer Care Network coordination: analysis in the light of the lean methodology for early diagnosis.

This study aimed to analyze the application of the lean philosophy in the Health Care Network (RAS) for the early diagnosis of breast cancer. This case study was produced with data from interviews, document analysis, and observation and was conducted from June to July 2019. The setting was the seat of the municipality of the North Metropolitan Region, Ceará State, Brazil, involving three points of the RAS (Primary Care Unit, Medical Specialties Center, and Polyclinic). The following issues were identified: long waiting times, first-come-first-served care, and insufficient medical workload. Implementing the theoretical model of lean philosophy would reduce the total process time from 36 days to 15 in the Primary Care Unit/Medical Specialty Center flow and from 33 to 13 days in the Primary Care Unit/Polyclinic. The presented model is an efficient reference for improving the management and early diagnosis of breast cancer in the RAS.

Coordenação da Rede de Atenção ao Câncer de Mama: análise à luz da filosofia lean para o diagnóstico precoce

Abstract This study aimed to analyze the application of the lean philosophy in the Health Care Network (RAS) for the early diagnosis of breast cancer. This case study was produced with data from interviews, document analysis, and observation and was conducted from June to July 2019. The setting was the seat of the municipality of the North Metropolitan Region, Ceará State, Brazil, involving three points of the RAS (Primary Care Unit, Medical Specialties Center, and Polyclinic). The following issues were identified: long waiting times, first-come-first-served care, and insufficient medical workload. Implementing the theoretical model of lean philosophy would reduce the total process time from 36 days to 15 in the Primary Care Unit/Medical Specialty Center flow and from 33 to 13 days in the Primary Care Unit/Polyclinic. The presented model is an efficient reference for improving the management and early diagnosis of breast cancer in the RAS.

The Experience of Limited Access to Care for Community-Based Patients With Spinal Cord Injury and Stroke in Nepal and the Potential of Telerehabilitation: A Qualitative Study.

This study explores the experiences of care received and management of disability for individuals with spinal cord injury and stroke following discharge from a specialty rehabilitation center, alongside perspectives on the potential role of telerehabilitation. We employed qualitative in-depth face-to-face interviews with patients who had accessed and been discharged from a specialist rehabilitation center in Nepal were used. Interviews sought perspectives of adjusting to, living with, and managing disability alongside the potential role of telerehabilitation in the community setting. Inductive thematic analysis was used to derive themes. A total of 17 participants with spinal cord injuries or stroke were interviewed. Four generated themes included: (i) Difficulties accessing support and perceived mismanagement following initial neurological injury; (ii) Realizing the magnitude and impact of an injury in the absence of clear routes to support; (iii) A multi-faceted symptom burden and its impact; and (iv) The nature and types of interaction with health professionals post-discharge and the potential role of telerehabilitation. We detail accounts of suspended periods with minimal or no support provided from healthcare providers for people with spinal cord injury and stroke following initial acute management. Telerehabilitation could be a worthwhile approach to enhance access to rehabilitation in the community setting but must accompany national efforts to enhance the provision of specialist rehabilitation.

Spatial-temporal analysis of hospitalizations with death caused by oral cancer in Brazil and its correlation with the expansion of healthcare coverage

Oral cancer (OC) is a growing public health problem worldwide. In Brazil, the National Oral Health Policy, implemented in 2004, expanded access to oral health services and prioritized OC care. However, it is not known whether this expansion resulted in a reduction in hospital admissions with death. This study aimed to analyze the proportion of hospital admissions who progressed to death due to OC in Brazil from 2007 to 2019 and its correlation with the coverage of health services. This study is an ecological, longitudinal, and analytical study of hospital admissions with death due to OC recorded in the Brazilian Hospital Information System. The following analyses were performed: descriptive, spatial (choropleth maps and Moran index), and negative binomial regression, with a hierarchical approach, estimating crude and adjusted regression coefficients (β) and respective 95% confidence intervals (95% CI) (alpha=5%). In 2019, Moran's index (I) of spatial autocorrelation showed a negative association between hospital admissions with death and dentist surgeon/inhabitant rate (I=-0.176), physician/inhabitant rate (I=-0.157), family health strategy (FHS) coverage (I=-0.080), oral health team (OHT) coverage (I= -0.129), dental specialty centers (DSC)/inhabitant rate (I= -0.200), and oncology bed/inhabitant rate (I= -0.101). In the adjusted regression analysis, the proportion of hospitalizations with deaths caused by OC was higher in Brazilian states with a lower medical ̸inhabitant ratio (β= -0.014; p=0.040), a lower dentists/inhabitant ratio (β= -0.720; p=0.045), a lower number of DSC (β= -0.004; p<0.000), a lower amount paid per hospitalization (β= -10.350; p<0.001), and a lower number of biopsies (β= -0.00008; p=0.010). The proportion of hospitalizations that progressed to death showed a positive association with the number of days of hospitalization (β= 0.00002; p=0.002). Increased health care coverage has decreased serious hospital admissions with deaths caused by OC in Brazil.

S-30-2: ASIAN MANAGEMENT OF HYPERTENSION: CURRENT STATUS, HOME BP MONITORING, AND SPECIFIC CONCERNS IN PHILIPPINES

Introduction: Cardiovascular disease (CVD) in the Philippines showed hypertension as the highest (38.6%), followed by stroke (30%), coronary artery disease (17.5 %), heart failure (10.4%). Risk factor were: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9% (BMI). Latest hypertension prevalence is 37%. Aware hypertensives were 19%, unaware was 18%. Treatment rate was 68%, compliance was 86%, blood pressure (BP) control rate was 37%. Mortality from CVD were stroke, mostly infarct (22.6%), MI (6.5%), Heart Failure (6.5%). Drugs used were angiotensin receptor blockers (64%), calcium channel blockers (42%), beta-blockers (6%), ACE inhibitors (4%) and diuretics (1%). Current status of home BP monitoring (HBPM): HBPM is performed by 23% of hypertensive population in the Philippine. Barriers to its use include cost, availability and lack of trust regarding the accuracy of digital BP devices. Currently, physicians encourage patients to monitor BP at home to better assess their treatment to rule out white coat, masked hypertension and other parameters. Philippine sub-analysis of AsiaBP@Home study: Data on HBPM offer solution to problems encountered particularly in Asia. Based on AsiaBP@Home study as a multi-national Asian specialty center performance regarding home and clinic BP control, majority of uncontrolled hypertension simulated by the new lower ACC/AHA guideline threshold gave additional 18% increase in sustained uncontrolled hypertension (SUCH) and to additional 5% increase in white-coat uncontrolled hypertension (WUCH). In a sub-group analysis of the Philippines in this study (Fig.1), using conventional threshold values, well-controlled clinic SBP was only 69% and well controlled morning home SBP was 79%. Using the new threshold levels, the well-controlled clinic SBP decreased to 43% and well controlled morning home SBP was lower at 67%. Comparing the conventional to the new thresholds, controlled hypertension decreased from 62% to 37%, masked morning hypertension decreased from 8% to 6%, Sustained hypertension increased from 13% to 27%, and white-coat hypertension increased from 18% to 31%. Summary: Hypertension still remains a major problem in the Philippines. Office BP measurement remains to be our standard for hypertension assessment and it appears to be insufficient in guiding us in our management approach. With the availability of newer and practical tools such as the HBPM, it will certainly improve hypertension evaluation, patient awareness, physician alertness in achieving better BP control and hence, better outcomes.

Surgical treatment outcome of children with neural-tube defect: A prospective cohort study in a high volume center in Addis Ababa, Ethiopia

IntroductionPrevalence of neural tube defects (NTD) is high thus many children are born with a neural tube defect in Addis Ababa, and surgical closure is a commonly performed procedure at the pediatric neurosurgical specialty center. Research questionThe primary aim is to study the outcomes in children undergoing surgical closure of NTDs and to identify risk factors for readmission, complications and mortality. Material and methodsSingle-center prospective study of all surgically treated NTDs from April 2019 to May 2020. ResultsA total of 228 children, mean age 11 days (median 4) underwent surgery during the study period. There were no in-hospital deaths. Perioperatively 11 (4.8%) children developed wound complications, none of them needed surgery and there was no perioperative mortality. The one-year follow-up rate was 62.7% (143/228) and neurological status remained stable since discharge in all. The readmission and reoperation rates were 38 % and 8 % and risk factors for readmission were hydrocephalus (80%) and open defects (88%). Hydrocephalus (P = 0.05) and younger age (P = 0.02) were identified as risk factors for mortality. The wound-related complication rate was 55% at and was associated with large defects (P = 0.04) and delayed closure due to late hospital presentation (P = 0.01). Discussion and conclusionThe study reveals good perioperative surgical outcome and further need for systematic improvement in treatment and follow-up of NTD patients especially with hydrocephalus. We identified risk factors for wound-related complications, readmission and mortality.

Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database.

Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. Among 62698 patients, 19506 (31.1%) underwent Robot-L and 43192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90593.0 vs 72733.3 USD, respectively, P < .001). In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Real-world abdominal aorta aneurysm screening patterns among patients with new or worsening of symptomatic peripheral artery disease

BackgroundPatients with peripheral artery disease (PAD) have an increased risk of abdominal aortic aneurysms (AAA), but it remains unclear whether practitioners are screening patients for AAA as part of routine PAD management. MethodsThe Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease (PORTRAIT) Registry is an international prospective registry of patients with new or worsening PAD symptoms presenting to 16 specialty centers in the United States, Netherlands, and Australia, from June 2011 to December 2015. Patients were stratified by AAA screening or AAA positivity. An adjusted median odds ratio was calculated for AAA screening rates across sites. ResultsOf the 1275 patients in the study, 871 (68%) were screened for AAA, with 53 (6.1%) having AAA. AAA screening rates did not differ significantly by country (p = 0.36), but there was a large variation across sites for documentation of AAA screening with an adjusted median odds ratio 12.0 (95% CI 4.7–93.1), with AAA screening rates ranging from 7% to 100% across vascular specialty centers. ConclusionsAmong patients with PAD in a multicenter registry, over two-thirds were screened for AAA, with 6% having documented aneurysms. A large variation was seen across clinical sites, suggesting efforts are needed to increase awareness for guideline implementation and establish new benefit-risk evidence inclusive of high-risk populations such as patients with PAD.

Association of Hormonal imbalance in menopausal women with cardiovascular disease in Erbil city

Menopausal women have a higher risk of cardiovascular disease (CVD), which is thought to be due to an imbalance in serum estradiol and total testosterone level. To find out the effect of menopause on sex hormone levels such as estrogen, testosterone, and progesterone in serum menopausal women and to elevate the relationship between these hormones and CVD. This case-control study included (224) participants (menopausal women with CVD and non-CVD) in the age range (of 40-69 years) who visited (The surgical specialty hospital cardiac center and Hawler teaching hospital). A self-administered questionnaire was used for data collection. Fasting serum metabolic parameters and hormones were measured which included (E2, TT, P, SHBG) and (Total Cholesterol, Triglycerides, HDL, LDL, and VLDL). Women with CVD represented 60.7%., who had previously been diagnosed by specializes in the cardiac center, and healthy menopausal women represented 39.3%. The mean value of E2 was significantly lower in menopausal women with CVD (20.066±1.773 Pg/ml vs 29.455±3.807 Pg/ml) along with serum progesterone level (0.234±0.0102 ng/ml vs 0.452±0.137 ng/ml) and SHBG level (31.705±1.085 nmol/L vs 37.191±1.804 nmol/L) compared to healthy menopausal women (for all, p&lt;0.05). On the other hand, a significantly elevated level of total testosterone (17.970±1.28 nmol/L vs 10.552±.99nmol/L) was observed in menopausal women with CVD compared with healthy women (p&lt;0.001). Multiple linear regression analysis showed the E2 negative correlation with LDL-C (p&lt;0.01), and TT negative correlation with HDL-C (P&lt;0.01). Low serum levels in terms of sex hormones, (E2, P, and SHBG) with high-level serum TT might be contributed to cardiovascular disease.

Association between management, human resources, and care provided to patients with special healthcare needs in dental specialty centers in Brazil: A cross-sectional study.

This study aimed to identify the association between management and human resource factors with the performance of dental care provided to patients with special health care needs (SHCN) in secondary care in Brazil in the second cycle of the Program for Quality Improvement and Access to Dental Specialty Centers (PMAQ-CEO). This study is a secondary data analysis from the second cycle from PMAQ-CEO, which evaluated 1097 Dental Specialty Centers (DSCs), conducted in 2018. Seventeen independent variables taken from dentists' training, and dental team management characteristics were analyzed to assess their influence on the reported "Performance of care for SHCN patients". An estimated score was generated from their performance on 23 questions related to the physical and human structure and work processes in the oral health care of SHCN patients in the DSCs. Negative binomial regression model with values p ≤ 0.05 were considered significant. Data analysis included residual deviation to the degree of freedom and the chi-square test. The patient care performance score with SHCN increases significantly when the DSC has a manager (RR=1.019; CI=1.011-1.026) and goal monitoring and analysis (RR=1.012; CI=1.007-1.005). By contrast, the DSCs in which the dentist is a statutory public servant (RR=0.998; CI=0.997-1.000) and performs additional unhealthy or hazardous duties (RR=0.998; CI=0.996-0.999) are less likely to provide a higher quality care. The heterogeneity and low-performance scores for dental care provided to SHCN was identified in Brazilian health services. It was possible to verify that management and human resource factors of the DSCs were associated with the performance of dental care provided to SHCN patients.

A Learning Health System Approach to Cancer Survivorship Care Among LGBTQ+ Communities.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals who receive primary care services at community health centers are often referred to external specialty care centers after cancer diagnosis, upon which primary care services are disrupted and may be discontinued because of gaps in communication between primary and oncologic care providers. This qualitative study evaluated barriers and facilitators to effective care coordination for LGBTQ+ patients with cancer and the utility of a novel cancer care coordination tool to mitigate identified barriers. Semistructured interviews with LGBTQ+ cancer survivors, caregivers to LGBTQ+ persons, clinical team members who provide care to LGBTQ+ patients, and members of community-based organizations that work with LGBTQ+ patients were conducted. Interview analysis was a multistage process, wherein a constant comparison approach was used. Transcripts were reviewed and coded using Atlas.ti Cloud. A total of 26 individuals were interviewed: 10 patients, four caregivers, 10 clinical care team members, and two community organization representatives. Interview analysis yielded insight regarding (1) LGBTQ+ patient experiences engaging with primary and oncologic care at the clinic level and (2) perceptions of patient-provider and provider-provider communication and coordination. Interview findings indicate a need for further development of interventions aimed at improving care coordination, patient experience, and outcomes in the cancer care continuum for LGBTQ+ patients. Learning health systems, like the one studied, show great potential for contributing to the development of such interventions.