Urgent Consultation Research Articles

Análisis del sistema XIDE en la gestión de la sobredemanda asistencial

ObjectiveTo assess the impact and suitability of the XIDE citation system in the management of over-demand for care at the Monforte de Lemos Health Center (Lugo, Spain). Material and methodsDescriptive, cross-sectional, observational and analytical study. The study population was the patients with appointments to the elderly in the ordinary agenda as «forced» or «urgent forced». The population sample was obtained during the period from July 15 to August 15, 2022. The comparative analysis was performed with periods prior to the implementation of XIDE and the XIDE/observer concordance was estimated by calculating Cohen's kappa index. ResultsWe observed an increase in care pressure, both in the number of consultations/day and in the proportion of forced consultations, which have increased by 30-34%. The group over 85 years of age and women are the majority in excess demand. The 83.04% of urgent consultations were cited through the XIDE system, the most frequent reason for consultation being «suspected COVID» (24.64%), with a concordance of 51.4% in this group and 65.5% globally. We appreciate a high overtriage in the assigned attention times, even when the reason for consultation coincides, with a poor statistical concordance with the observers. The high proportion in the overdemand of patients belonging to other places in the health center stands out, so that adequate management of human resources with adequate coverage of absences would reduce it by 48.5%, while the XIDE system (in the ideal assumption of absolute concordance) would only manage to reduce it by 43%. ConclusionsThe low reliability of the XIDE is mainly due to inadequate triage, rather than the failure to reduce overdemand, so it cannot replace a triage system performed by health personnel.

Change in urgent psychiatric consultations during the first lockdown in Venezia: a multicenter, retrospective study

IntroductionThe COVID-19 pandemic has affected the mental health of the global population (Dragioti et al. J Med Virol 2022;94(5):1935-49). The first lockdown brought the hardest and most sudden impact on work, educational, social, and recreational activities. Moreover, the fruition of mental health services was restricted, and non-urgent appointments were delayed or converted into telepsychiatry. Thus, it was reasonable to hypothesize different trends of urgent consultations regarding mental health.ObjectivesTo detect quantitative and qualitative changes in patients presenting to our Emergency Departments (ED) during the early phase of the pandemic compared to the previous year.MethodsWe conducted a retrospective, multicenter study in Venezia (historical center, mainland) through systematically reviewing the psychiatric consultations in our ED, during the first 16 weeks since 8-Mar-2020 and the same period of 2019. The protocol was approved by the local Ethics Committee as UPSI-19 (Urgent PSychiatric consultations In COVID-19). The statistical analysis was conducted with the software R; Interval Risk Ratio (IRR) with 95% CI was calculated for absolute frequency, primary diagnosis, leading symptoms, and outcomes of these consultations.ResultsIn the early phase of the pandemic, in our ED we assisted to a significant decrease in psychiatric consultations: 372 vs 441, IRR=0.84(0.73-0.96). Data revealed a reduction of referral for suicidal behavior (IRR=0.52(0.33-0.80)) and anxiety symptoms (IRR=0.60(0.42-0.87)). Primary diagnoses of patients were not different between the two periods explored. There was a slight increase in admissions (150 vs 121), and a significant decrease in less severe clinical pictures.ConclusionsIn the timeframe considered, we assisted to a significant decrease in referrals from the ED, possibly related both to fewer non-locals and to less frequent non-severe presentations. Despite the type of patients (for underlying diagnoses) remained unmodified, an interesting reduction of anxiety symptoms and suicidal behavior was noticed. Literature from ED studies during the first wave are consistent with our finding regarding the number of visits; suicide attempts seemed unmodified or decreased elsewhere (Giner et al. Curr Psychiatry Rep 2022;24(1):1-10). Limitations of our study include peculiarities of the Venetian territory, limited sample and time of observation. Future directions encompass the integration with data from the community setting and later developments.Disclosure of InterestNone Declared

Suicide attempts and eating disorders in adolescents, the mental health wave of the second year of the COVID-19 pandemic: A paediatric emergency department perspective.

We compared adolescents' visits to a tertiary-level paediatric emergency department (PED) in Italy during the pre-pandemic year and the first and second years of the COVID-19 pandemic, focusing on mental health presentations. This was a retrospective study. We collected the number of visits, the demographical features, triage codes, discharge diagnoses, and outcomes of adolescents 13-17 years old who accessed the PED from 1 March 2019 to 28 February 2022. During the study period, 13,410 adolescents accessed the PED. The number of visits related to mental health problems was 304 (6.4%) in the second year of the pandemic and 306 (5.6%) in the pre-pandemic year, p = 0.07. In the same periods, females' prevalence was higher, 220 (72.4%) vs. 197 (64.4%), p = 0.03. The absolute number of subjects needing admission increased, 44 vs. 34, p = 0.21, and more urgent psychiatric consultations were needed, 161 vs. 114, p < 0.0001. The number of suicide attempts was 23 vs. 8, +188%, p = 0.01. The number of adolescents with eating disorders was 21 vs. 5, +320%, p = 0.001. PED visits for suicide attempts and eating disorders in adolescents sharply increased in the second year of the pandemic.

Rapid Amniotic Fluid Assessment for Cervical Cerclage Placement

A 22-year-old female whose first pregnancy resulted in the delivery of a full-term healthy newborn presented at 20 weeks gestation in her second pregnancy for urgent maternal fetal consultation. A recent ultrasound diagnosed a short cervix of 20 mm. A pelvic exam revealed 1 to 2 cm of cervical dilation and the urgent need for cervical cerclage placement to reduce the risk of preterm delivery and fetal demise. Amniocentesis was carried out, and cultures, glucose, and lactate dehydrogenase testing were performed on the amniotic fluid to quickly exclude chorioamnionitis prior to the operation (Table 1). ... ... Amniotic fluid glucose and lactate dehydrogenase test results can aid physicians when assessing the risk of ascending infection before cerclage placement and are available within hours compared to cultures (2–3 days). Median glucose and lactate dehydrogenase concentrations in intraamniotic infections are 4.5 mg/dL and 1084 IU/L, respectively (1, 2). Glucose <15 mg/dL and lactate dehydrogenase > 250 U/L demonstrate 73.3%/57% sensitivity and 88.1%/87% specificity, respectively for chorioamnionitis (3, 4). Our patient did not have an infection. Common culture isolates include Ureaplasma urealyticum and Mycoplasma hominis (5).

Renal colic: an update

The prevalence of renal colic is 20 % with a high recurrence rate. It remains a frequent reason for consultation in the emergency room. In case of uncertainty about the diagnosis, a decisional aide, the STONE score, can be used. Low-dose CT remains the standard, but studies show a role for ultrasound in the diagnosis to reduce the costs and cumulative effects of radiation. Most simple renal colics are treated with medical expulsive therapy which consists of anti-inflammatory, and an alpha blocker. It is important to identify patients who require urgent urological consultation or follow-up by urologists.

Profile of Dermatology Consultations for Inpatients: The Scope for Telemedicine During the COVID-19 Pandemic and Beyond

Background: Attending dermatology consultations for inpatients is an integral part of the role of dermatologists inpatient care. Materials and Methods: A retrospective study was conducted at a large tertiary care hospital when the country, particularly the city, was severely affected by the COVID-19 pandemic. The aim was to study the profile of dermatology referrals for inpatients at the time of the COVID-19 pandemic and assessing the need for telemedicine in these inpatients. Results: A total of 341 dermatology consultations for 288 patients were received. Most of the consultations were from internal medicine (15.3%) and obstetrics and gynecology (8.7%). Around 65% of consultations were for new-onset (≤30 days) skin conditions while around 35% were for chronic (&gt;30 days) conditions. The most commonly seen conditions were superficial fungal infections (14.9%) followed by eczematous disorders (13.2%). On grading the level of urgency of the referrals, 34.4% required an immediate consultation, 41% required it within a week, 12.8% within 2–4 weeks, 8% within 1–3 months, and 3.8% after the pandemic settles. The need for urgent consultation was more in acute cases than in chronic cases (P = 0.00). 62.5% of the consultations could have been done by telemedicine. Conclusion: As a majority of the consultations were for common and straightforward skin conditions and could mostly be done on telemedicine, this study underlines the need for strengthening the telemedicine services for inpatients referrals during this COVID-19 pandemic and even beyond.

Extreme intraocular pressure and steroid-dependent iritis.

A 50-year-old ophthalmic technician was referred by her retina specialist for urgent consultation due to markedly elevated intraocular pressure (IOP) unresponsive to medical therapy. Her history included chronic polyarticular juvenile rheumatoid arthritis and chronic uveitis requiring ongoing topical steroid therapy. She had a sub-Tenon injection of Kenalog (triamcinolone) 18 months prior to referral. Chronic topical anti-inflammatory therapy included nepafenac (Ilevro) and prednisolone acetate 2 times a day. Attempts to discontinue topical steroid resulted in worsening inflammation. The patient was referred when the IOP measured 44 mm Hg in the left eye despite aggressive medical therapy, including acetazolamide. The IOP improved slightly when loteprednol was substituted for prednisolone acetate. Current medications in the left eye include brimonidine 3 times a day, loteprednol 2 times a day, nepafenac 2 times a day, and fixed combination latanoprost + netarsudil at bedtime. Her only medication in the right eye was travoprost. She is intolerant to dorzolamide. She was also taking acetazolamide 500 mg 2 times a day. She was not taking any anticoagulants. Past surgical history included cataract surgery in each eye. She has not had laser trabeculoplasty in either eye. Examination revealed uncorrected visual acuity of J1+ in the right eye (near) and 20/30 in the left eye (mini-monovision). There was no afferent pupillary defect. There was mild band keratopathy in each eye while the central cornea was clear in both eyes without keratic precipitates. Here angles were open to gonioscopy without peripheral anterior synechia. There was mild to moderate flare in each eye with trace cells. The IOP was 17 mm Hg in the right eye and 31 mm Hg in the left. Central corneal thickness measured 560 μm and 559 μm in the right and left eye respectively. There was a well-positioned intraocular lens within each capsule with a patent posterior capsulotomy. There was mild vitreous syneresis but no vitreous cell. The cup to disc ratio was 0.5 in each eye with a symmetrical neural rim. The retina was flat without macular edema. Visual field was normal in both eyes (Figures 1 and 2). Optical coherence tomography of retinal nerve fiber layer (RNFL) is shown in Figure 3 and retinal ganglion cell layer is shown in Supplemental Figure 1 (http://links.lww.com/JRS/A756).JOURNAL/jcrs/04.03/02158034-202301000-00020/figure1/v/2022-12-26T045736Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202301000-00020/figure2/v/2022-12-26T045736Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202301000-00020/figure3/v/2022-12-26T045736Z/r/image-tiff Please comment on your management of this patient's left eye.

Thrombotic Thrombocytopenic Purpura in a Parturient Leading to Life-Threatening Thrombocytopenia and Neonatal Demise—A Case Report

Abstract Thrombocytopenia is common (up to 12%) in pregnancy; thrombotic thrombocytopenia is a rare cause of thrombocytopenia; however, it is immediately life-threatening to both mother and fetus and requires immediate intervention. This is compounded by the need to act on a presumptive diagnosis with high level of suspicion given the relatively long laboratory confirmation time. A 31-year-old gravida 3, para 1 parturient at 26 weeks of gestation presented to outside hospital with recent onset of easy bruising and blurry vision. A blood count was drawn and showed a platelet count of 19,000/μL. She was transferred to our institution for management where an initial diagnosis of preeclampsia with severe features was made based on thrombocytopenia and fetal growth restriction (&lt;1%). Platelet count nadired at 14,000/μL and a blood smear showed schistocytes, suggesting microangiopathic hemolysis, prompting discussion of urgent cesarean delivery and anesthesia consult. An urgent hematology consult led to presumptively diagnosing thrombotic thrombocytopenic purpura and cesarean delivery was deferred after discussion with the patient and team. Plasma exchange and steroid therapy were started promptly, and her platelet count improved within 12 hours. Unfortunately, the patient experienced neonatal demise. Undetectable ADAMTS13 levels confirmed diagnosis of thrombotic thrombocytopenia. She was transitioned to rituximab, platelets recovered to baseline, and she continues to do well. Thrombotic thrombocytopenia is a rare, life-threatening cause of thrombocytopenia in pregnancy. Despite grim fetal prognosis, especially in early pregnancy, low threshold of suspicion, early anesthesia involvement, and multidisciplinary approach can facilitate diagnosis and timely intervention. In our case, it was likely lifesaving.

Orbital Fractures and Risk Factors for Ocular Injury.

To identify factors predictive of serious ocular injury requiring urgent consultation by ophthalmology in patients presenting with blunt trauma orbital fractures. This is a retrospective study of adult patients diagnosed with orbital fractures after blunt trauma at a university medical center emergency room. Patient records were examined over a three-year period. Data including mechanism of injury, fracture location, ocular symptoms, and examination findings were recorded. Ocular injuries were divided into three levels of severity: mild, moderate, and severe. Fracture characteristics, patient demographics, and examination findings were analyzed using multinomial regression to identify risk factors for more severe injury. One hundred and eighty-six patients met inclusion criteria. For 29.6% of patients, urgent ophthalmologic consultation was required. Ruptured globes occurred in 2.2% of injuries. There was a statistically significant association between severe ocular injury and three examination findings: poor vision (OR 14.5; p < 0.001), afferent pupillary defect (OR 44.8; p < 0.001), and abnormal pupillary reaction (OR 28.0; p < 0.001). Likewise, blurry vision (OR 3.6; p = 0.018), ocular pain (OR 3.7; p = 0.011), and facial pain (OR 4.4; p = 0.031) were also associated with an increased risk of severe ocular injury. Abnormal pupillary reaction was associated with moderate injury (OR 4.5; p = 0.041). Demographic factors, mechanism of injury, anti-coagulant use, fracture location, diplopia, no documented vision, subconjunctival hemorrhage, chemosis, and motility restriction were not associated with injury severity. Most patients who presented to the emergency room with an orbital fracture did not require urgent ophthalmologic consultation. The presence of blurry vision, ocular pain, facial pain, poor vision, and afferent pupillary defect significantly increased the odds of severe injury. Abnormal pupillary reaction was associated with both moderate and severe injury.

Young patient with thunderclap headache, seizure activity, and fixed eye deviation.

A 39-year-old female with a history of iron deficiency anemia presented to the emergency department (ED) with a 3-hour history of severe headache followed by acute-onset projectile non-bilious, non-bloody vomiting, acute mental status change, and seizure-like activity. The onset of the headache was spontaneous and described as the worst headache of her life. Vomiting and seizure-like activity began several hours after the onset of headache, and emergency medical services (EMS) were called at that time. The patient was found to be unresponsive by EMS. Upon arrival to the ED, the physical examination was notable for fixed left eye deviation, intermittent withdrawal from noxious stimuli, and spells of sustained clonus in the lower extremities greater on the left than the right. The patient was given 2-mg intravenous lorazepam with minimal improvement in the tonic–clonic activity. The patient was hemodynamically stable and had an oxygen saturation of 98% on room air. Initial laboratory test results were significant for anemia (hemoglobin = 5.2 g/dL, hematocrit = 21%) and elevated platelets (426.5). Computed tomography (CT) of the head, CT angiogram of the head and neck, CT venogram of the head, and urgent neurology consult were obtained immediately after arrival to the ED. The patient continued to decline after CT and was intubated for airway protection. Imaging was suggestive of acute venous sinus thrombosis extending from the superior sagittal sinus to the right cranial jugular vein with no definite intracranial hemorrhage (Figures 1 and 2) and bilateral segmental and subsegmental pulmonary emboli (Figure 3). This case describes a typical presentation of cerebral venous sinus thrombosis (CVST). CVSTs are more commonly seen in women aged 30–50 years.1 Commonly, sinus thrombosis can lead to subarachnoid hemorrhage with a subsequent “thunderclap” headache that can lead to neurological symptoms.3 Neurology evaluated the patient in the ED, and the patient was taken to the operating room for an aspiration thrombectomy and started on a continuous heparin infusion. The patient had gradual improvement of symptoms after 1 week of inpatient care in the neurology intensive care unit. At discharge, she was started on indefinite anticoagulation and levetiracetam for seizure prophylaxis. Further workup showed no evidence of hypercoagulability, no recent trauma, and no oral contraceptive use. CVST is defined as occlusion of dural sinuses leading to decreased venous flow, an increase in intracranial pressure, decreased cerebral perfusion pressures, and dilation of the cerebral veins. Continued hypoperfusion can result in ischemic tissue damage, resulting in acute neurologic symptoms such as seizures, headaches, altered mental status, and increased intracranial pressure. Without treatment, the thrombus can damage vessel walls, increasing the chances of vessel rupture, leading to subarachnoid hemorrhages and decreased cerebrospinal fluid outflow.1 Common risk factors for CVSTs include recent trauma, malignancy, thrombophilia, infection, obesity, oral contraceptive use, and increased estrogen states such as pregnancy.2

Efficacy of a Photograph-Based Triage System Initiated During the COVID-19 Pandemic to Identify and Streamline Pediatric Foot and Ankle Referrals

Background: The COVID-19 pandemic required hospitals to reduce in-person visits. Although most pediatric foot and ankle conditions do not require urgent consultation, clubfoot (CF) relies on early identification and treatment. To avoid unnecessary hospital visits for infants, we developed a triage system using standardized clinical photographs of the child's feet taken by the parents for clinician review. This study assesses the efficacy of this triage system based on accuracy of the triage diagnosis (TDx) and time from referral to initial consultation (IC).Methods: This is a retrospective cohort review of patients referred to a tertiary care pediatric institution for a foot and ankle condition from 03/16/20 to 09/15/20 (onset of COVID-19), and from the same period in 2019 (prior to use of the triage system). Patients were identified by referring diagnosis (RDx). Patients were excluded if they missed their initial visit or the RDx was not clear. Chart review was performed to collect demographic data, clinical photographs, RDx, TDx, IC diagnosis, and time to IC. Diagnosis accuracy (DA) scores were assigned: 0 when RDx or TDx did not match diagnosis at IC, 0.5 if the diagnosis was partly correct, and 1 when diagnoses aligned. Sensitivity and specificity of the photo-based triage system were calculated for patients referred for clubfoot.Results: Of the 118 patients included, 62 were referred for CF and 56 for other foot and ankle conditions (FA). In 2020, 23/27 CF and 11/12 FA patients sent photographs. The average time to IC for FA patients was similar in both years (142 days in 2019 vs. 183 days in 2020, p=0.24), while the average time to IC for CF decreased from 66 days in 2019 to 31 days in 2020 (p=0.08). Accuracy for TDx in 2020 was high for CF (0.98) and FA (0.92) patients (p=0.49). Sensitivity and specificity of TDx for clubfoot patients were 100%.Conclusion: Triage diagnosis was accurate and time from referral to consultation decreased for clubfoot patients from 2019 to 2020, supporting that this novel photo-based triage system for pediatric foot and ankle referrals is effective in identifying urgent consults and ensuring timely assessment.Level of Evidence: III Key Concepts•Diagnosis of pediatric foot and ankle conditions by clinical photographs submitted by parents is accurate.•Triage of pediatric foot and ankle referrals with submitted clinical photographs enables appropriate streamline of urgent consultations and avoids unnecessary visits for self-resolving conditions.•Wait times for urgent consultations decreased with adoption of a photo-based triage system.

ODP498 Myocardial Ischemia precipitating thyroid storm diagnosed during recovery through Wellen's wave: An ECG for an eye

Abstract Introduction: Thyroid storm is a major life-threatening condition in a patient of thyrotoxicosis which can accelerate the cardiovascular morbidity in forms of tachycardia, arrythmia and congestive heart failure. It can be precipitated by acute coronary syndrome. Most literatures have reported acute coronary syndromes during the presentation itself but here we shall describe an intriguing case where the diagnosis was possible after the resolution of the thyroid storm. Clinical case: A 55-year-old graves’ disease patient had presented with classical features of thyroid storm which was precipitated by discontinuation of the anti-thyroid drugs. His initial electrocardiogram (ECG) showed sinus tachycardia. He was promptly started on intravenous fluid, 80 mg of daily carbimazole along with lugol's iodine and intravenous dexamethasone. Within 48 hours of treatment, his vitals became normal with resolution of the thyroid storm. His thyroid hormone status also showed marked improvement (free T4 falls from 90.31 ng/dl to 2.31 ng/dl) (normal range: 0.7 ng/dl-1.7 ng/dl). Due to his persistent jaw pain, mild chest discomfort and hiccough, ECG recordings were done in regular intervals. Interestingly it showed dynamic changes consisted of biphasic T waves. This ECG changes were seen after the resolution of the thyroid storm features. The cardiac enzymes were within normal limits. We thought of wellen's syndrome and sought urgent cardiological consultation. Coronary angiography reveals left anterior descending artery (LAD) obstruction and patient promptly underwent percutaneous transluminal angioplasty. Patient's angina equivalent symptoms had resolved remarkably. He recovered satisfactorily and was discharged after 5 days. Clinical lesson: Ischemic heart disease is a well-known co-morbidity in a case of thyroid storm which can be identified at the initial presentation. But here the dynamic changes of ECG appeared after the resolution of the thyroid storm. It was classical of type A wellen's wave which is a harbinger of imminent massive anterior myocardial wall infarction due to near-complete blockage of LAD. Initial sinus tachycardia probably had hindered the appearance of typical wellen's wave in this case. But as soon as the thyroid storm resolved, typical dynamic changes appeared in the form of wellen's wave. Early suspicion due to following serial dynamic ECG changes has prevented a major catastrophe in this case. This case highlights the importance of tracking serial ECG changes in a patient of thyroid storm which can unmask any underlying ischemic cardiac disease even after apparent improvement of the clinical status. This clinical case also reports a unique association of thyroid storm and type A wellen's syndrome. Presentation: No date and time listed

Infectious Disease Teleconsultation to the Deployed U.S. Military From 2017-2022.

The ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program is a synchronous telemedicine system developed in 2017 to provide 24/7 remote expert support to U.S. Military and NATO clinicians engaged in medical care in austere locations. Infectious disease (ID) remains the highest consulted service since 2018 and is currently staffed by 10 adult and pediatric ID physicians within the Military Health System. We conducted a retrospective review of the ID ADVISOR calls between 2017 and 2022 to identify trends and better prepare military ID physicians to address urgent ID consultations in overseas settings. Health records of the ID consultations between July 2017 and January 2022 were reviewed for local caregiver and patient demographics, case descriptions, consultant recommendations, and outcomes. A "not research" determination was made by the Brooke Army Medical Center Human Research Protections Office. ID physicians received 57 calls for 60 urgent patient consultations. Most calls were from countries in the Middle East or in Southwest Asia (United States Central Command (USCENTCOM)), followed by countries in Africa (United States Africa Command (USAFRICOM)). The majority of patients were active duty U.S. Military and were generally male with median age of 25 years. All consults involved an initial phone consultation and 30% continued over email. Ninety percent of the calls were initiated by physicians, and the median time from injury or illness-onset to consult was 3 days. Seventy percent of the consult questions involved treatment and further diagnostics, but one-third of cases required assistance with management of disease prevention. Multidrug-resistant or nosocomial infections, animal or bite exposure, malaria and malaria prevention, febrile illness, and blood-borne pathogen exposure accounted for 63% of the consults. Collaboration with other specialties took place in a minority of cases, and follow-up contact was recommended 20% of the time. Most recommendations involved adjusting drug regimens or further testing. Medical evacuation was only recommended in five of the cases. Although there was limited ability for follow-up, no known deaths occurred. A high proportion of calls to the ID ADVISOR line are relevant to the overlapping content areas of infection prevention, force protection, and outbreak response. Most patients requiring urgent ID consultation were managed successfully without evacuation. The current military-unique ID fellowship curriculum is consistent with the encountered diagnoses per the ID ADVISOR line, and high-yield individual topics have been identified.

Evaluating awareness, knowledge and practice of healthcare professionals following implementation of a revised pregnancy prevention programme for isotretinoin in Ireland: A multi-stakeholder cross-sectional study.

In 2018, following an EU-wide safety review, a revised pregnancy prevention programme (PPP) was introduced for isotretinoin (Roaccutane®). This study aimed to examine awareness, knowledge, and experience implementing the revised isotretinoin PPP in clinical practice across three healthcare professional (HCP) groups in Ireland. A cross-sectional study using anonymous online surveys among general practitioners (GPs), community pharmacists, and specialist consultants was undertaken. Descriptive analyses are presented. Across all HCP groups there was high (≥87%) awareness that oral isotretinoin is contraindicated in women of childbearing potential (WCBP) unless the conditions of the PPP are fulfilled, but varying awareness among GPs (54.9%) and community pharmacists (45.9%) that exposure during pregnancy can cause both severe fetal malformations and spontaneous abortions. Implementation of the PPP in clinical practice varied across HCP groups. When initiating isotretinoin in WCBP, 66.7% of specialists and 40.8% of GPs indicated they had considered alternative treatment options, and 71.4% of specialists and 31.6% of GPs reported they first requested a pregnancy test. There was limited provision of the patient reminder card to WCBP, where 26.1% of community pharmacists provide this at each dispensing, while 47.6% of specialists and 11.8% of GPs ensured WCBP had a copy of the card when initiating treatment. Across all HCP groups, there was high (≥81.6%) awareness of the need for urgent consultation and immediate cessation of isotretinoin in the event of an unplanned or suspected pregnancy. Reinforcement of the provision and utilisation of the isotretinoin patient reminder card may be required, and further targeted education on specific elements of the PPP should be considered for GPs and community pharmacists.

Malaria Surveillance - United States, 2018.

Malaria Surveillance - United States, 2018.

Outcomes of a Hybrid Ophthalmology Telemedicine Model for Outpatient Eye Care During COVID-19

The hybrid ophthalmology telemedicine model asynchronously pairs an imaging appointment by a technician with a subsequent virtual appointment by a clinician. Although it has been mentioned in several studies as an alternative to standard in-person care during the COVID-19 pandemic, outcomes of this alternative clinical care model remain to be evaluated. To investigate the outcomes associated with the hybrid ophthalmology telemedicine model during the COVID-19 pandemic for nonurgent and nonprocedural ophthalmological care. Retrospective, cross-sectional study of all hybrid visits scheduled during the year 2020 in a single academic, hospital-based eye clinic in Boston, Massachusetts. All hybrid ophthalmology telemedicine visits completed in the year 2020 by opthalmologists and optometrists were included. Data were analyzed from January to December 2020. Hybrid telemedicine clinical encounters. Four outcome metrics were calculated: (1) need for subsequent procedure visit, (2) medication change, (3) nonurgent, and (4) urgent consultation with another eye clinician. Adverse outcomes were defined as irreversible vision loss and the need for additional in-person evaluation to reach a management decision. From April 9 to December 30, 2020, 889 patients (506 female patients [56.9%]; mean [SD] age, 62.1 [14.5] years; age range, 13-98 years) completed 940 hybrid visits. The most common visit indications were glaucoma (424 visits [45.1%]) and retinal diseases (499 visits [53.1%]). A total of 25 visits (2.7%) led to a procedure, 22 visits (2.3%) led to a change in medication, and 44 visits (4.7%) were referred for nonurgent consultation with another subspecialty with no instances of urgent referrals. Sixteen patients (1.7%) were referred to the on-call clinician for a same-day emergency in-person visit or recommended for a subsequent standard in-person visit to reach a management decision. There were no cases of irreversible vision loss following a hybrid visit. These findings suggest that with the appropriate patient selection and clinical setting, the hybrid ophthalmology telemedicine model may be a good alternative to standard in-person visits, particularly for patients with glaucoma and retinal diseases.

Effect of ElectroMagnetic interference from SmartPHone on cardiac ImplaNtable electronic device (EMI-PHONE study).

BackgroundSmartphone can emit two types of electromagnetic waves, static field and dynamic field. Evidence showed the interference from phones to cardiac implantable electronic devices (CIEDs). The smartphones and CIEDs are reportedly better designed to reduce electromagnetic interference (EMI).Methods80 consecutive subjects with CIEDs were recruited and tested for EMI. Subject was tested with three different smartphones (Nokia 3310, Iphone 7, and Samsung 9S). Phone was attached to chest wall at 0 cm at generator site, at atrial lead level, and at ventricular lead level. During the tests, real‐time interrogations were performed to detect any EMI from smartphone in standby mode, and during calling‐in and out for 30 s. After the tests, post‐test interrogations were performed to detect any parameter change. Adverse events including pacemaker inhibition, false ICD shock, CIEDs device malfunction, and urgent electrophysiologist consultations were recorded.Results80 subjects (mean age 70.5‐year‐old, 50% male) recruited in the study, all completed the testing protocol. The most common type of CIEDs tested was pacemaker (N = 56, 70%), followed by ICD (N = 16, 20%), and CRT (N = 8, 10%). Most patients (N = 62, 77.5%) had more than one lead implanted. The mean year of implantation was 5.2±2.8 (devices were implanted from 2008 to 2019). Of all the tests performed, there was no EMI or adverse events observed.ConclusionCurrent generation of smartphones has no EMI effect on CIEDs in our study and can be used safely with less concern about adverse events including pacemaker inhibition, inappropriate ICD shock, and CIEDs device malfunction.

Emergency surgical consultation for cancer patients: identifying the prognostic determinants of health

BackgroundPatients with malignancy often require urgent surgical consultation for treatment or palliation of disease. The objective of this study is to explore the prognostic determinants affecting care in acute cancer-related surgical presentations and the effect on patient outcomes.Main bodyThis is a retrospective review of patients referred to the acute general surgery (ACS) service at a tertiary hospital for management of cancer-related problem from July 2017 to September 2018. Patient demographics, course in hospital, and survival were recorded. Multivariant logistic regression and Kaplan-Meier estimates were performed. One hundred eighty-nine patients were identified (53% female) with a mean age of 65.9 years. Forty-two patients (22%) were newly diagnosed with cancer on presentation, and 94 (50%) patients had metastatic disease. Cancer staging was completed in 84% of patients, and 65% had multidisciplinary team (MDT) assessment during their hospital stay. Surgery was performed on 90 (48%) patients, of which 31.2% was with palliative intent. Overall mortality was 56% with 30- and 60-day mortality of 15% and 22%, respectively. The adjusted odds ratio (OR) for a 60-day mortality was high in patients presenting with new cancer diagnosis (OR 3.18, 95% CI 1.18–9.02, p=0.03), metastatic disease (OR 5.11, 95% CI 2.03–12.85, p=0.001), or systemic therapy on presentation (OR 3.46, 95% CI 1.30–9.22, p=0.013).ConclusionEmergency surgical referral is common in patients with malignancy. Surgical decision making can be challenging due to the heterogeneity of this population and their associated comorbidities. Optimizing prognostic determinants such as goal-directed palliative care, MDT discussions, and bridging to systemic therapy can improve patient outcomes.

Changes in self-harm- and violence-related urgent psychiatric consultation in the emergency department during the different stages of the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 pandemic significantly affected emergency department (ED) visits and urgent psychiatric consultation (UPC) seeking behavior in EDs. Our study explored the changes in UPCs during and after the pandemic peak.MethodsThis retrospective observational study evaluated UPCs in the ED of a referral medical center in Taiwan, where treated both physical and psychiatric complaints. We defined the COVID-19 pandemic peak period as calendar week 4–18, 2020. The corresponding baseline as calendar week 4–18, 2019, and the slack period as week 4–18, 2021. The total number of UPCs, patient demographic data such as sex and age of the patients seen, the referral system (whether police or emergency medical service [EMS] or other sources), and the chief complaint (self-harm or violence) were recorded.ResultsCompared with the baseline period, a significant decline in UPCs was observed in the pandemic peak period, and a rebound was observed in the slack period, with the median [IQR] Q1, Q3 values of 22 [18, 26], 12 [10, 17]), and 16 [15, 23], respectively. We observed significantly few men (34.9% vs 45.2%) and less violence (10.2% vs 17.6%) in the peak period compared with in the baseline period, but no significant difference was found compared with the slack period. Throughout the pandemic, younger patients (41.8 ± 17.4 in 2019, 39.2 ± 18.5 [p = 0.121] in 2020, and 35.6 ± 17.2 [p < 0.001] in 2021), higher proportions of police/EMS referral (38.7% in 2019, 41.9% [p = 0.473] in 2020, and 51.9% [p = 0.001] in 2021) and self-harm–related complaints (57% in 2019, 62.4% [p = 0.233] in 2020, and 64.9% [p = 0.049] in 2021) was noted among UPC seekers during the pandemic. However, the proportion of violence-related UPCs (17.6% in 2019, 10.2% [p = 0.023] in 2020, and 12.3% [p = 0.072] in 2021) declined.ConclusionsThis study found that UPCs changed throughout the pandemic. This result raises the concern that mental health needs are masked during the pandemic.

The Evaluation of the Comparision Between pre- and post Pandemic Era Regarding Emergency Psychiatric Consultations

IntroductionCOVID-19 had direct and indirect impacts on both mental health and healthcare systems. Evaluating urgent psychiatric consultations may be useful to determine the effects of COVID-19 pandemic since it reflects the condition of psychiatric patients and healthcare systemsObjectivesThis study aims to determine the quantitative or qualitative changes in emergency psychiatry consultations after COVID-19 pandemic.MethodsThe socio-demographic characteristics and clinical features of two hundred thirty three patients were retrospectively collected and analyzed in order to compare the emergency psychiatry consultations before (between the dates 11th of March 2019-10th of March 2020) and after (between 11th of March 2020-10th of March 2021) the COVID-19 pandemic.ResultsThe ratio of patients consulted to psychiatry to total emergency department increase after pandemic (%0.03 vs %0.07). Among these patients, the diagnosis of ‘alcohol and substance use disorder’ (%6.1 vs. %15.4) (p=0.03) increased while the diagnoses of ‘obsessive compulsive disorder (5.3% vs. 0%)(p=0.01) and bipolar disorder (%21.1 vs. %20.5) (p=0.02) decreased. Hostility among patient during consultation increased (%19.1 vs. %30.8)(p=0.04). Suicidal thoughts decreased (%25.2 vs. %14.5) (p=0.04). Furthermore, voluntary inpatient treatment (%20.9-%34.2) (p =0.02) increased, transfer to another clinic (%25.2 vs. %12) (p=0.01) and outpatient treatment (%46.1 vs. %42.7) (p=0.01) decreased. An increase in oral treatments (%10.4 vs. %26.5) (p=0.02) and decrease in parenteral treatments (%71.3 vs. 54.7) ( p=0.01) were also reported.ConclusionsOur findings confirmed that after COVID-19 spread the clinical features diagnosis, and treatment modality have changed among urgent psychiatric consultations.DisclosureNo significant relationships.