Time Of Visit Research Articles

Factors associated with footpad dermatitis in German laying hens: A retrospective study

AbstractFootpad dermatitis (FPD) is characterized by lesions on the plantar region of the footpad. It is one of the most common foot health problems and welfare issues mainly described for broilers and turkeys. This retrospective study aimed to evaluate the presence of this footpad disorder in laying hens as well as to identify typical risk factors for FPD during the laying period. Data were collected from 39 German laying hen flocks visited up to 16 times during production, where the housing system, flock size, age of flock, season, litter type and quality as well as hens' foot health were recorded in 30–200 randomly selected animals/visit using a four‐point scoring system (FPD‐Score 0–3). In total, 15,448 randomly selected laying hens were scored and classified, recording the highest degree of FPD per animal as well as whether FPD was detected in one or both of its feet. Of the hens examined, 78.9% showed no alterations, 18.6% showed slight ones, 2.2% moderate alterations, and 0.3% showed severe FPD. In the animals related to FPD (n = 3253), 48.0% of the hens showed an alteration in one foot and 52.0% in both feet. While few animals showed FPD at the first two visits (AF0, AF1), the percentage of animals related to FPD increased at the laying peak (~28th week of life). At the end of the laying period, 34.4% of the hens showed at least slight alterations (n = 955/2776). The results of the statistical analysis showed that the FPD‐Score was statistically affected by the type of litter, the season, and the age of flock (all P < .0001), while the quality of litter at the time of visit (P = .0940), the housing system (P = .2696), and flock size (P = .8776) were not related to FPD. In summary, this study detected that more than a third of the animals examined showed alterations in their footpads at the end of the laying period. Such changes in foot health occurred from the laying peak and increased to the end of the laying period. In addition to the age of the hens, the type of litter and the season were determined as potential risk factors. Moreover, this study shows how common this foot health problem is, not only in turkeys and broilers but also for laying hens.

Implementation of an “opt-out” tobacco treatment program in six hospitals in South Carolina

ObjectiveDescribe the screening, referral, and treatment delivery associated with an opt-out tobacco treatment program (TTP) implemented in six hospitals varying in size, rurality and patient populations.MethodsBetween March 6, 2021 and December 17, 2021, adult patients (≥ 18 years) admitted to six hospitals affiliated with the Medical University of South Carolina were screened for smoking status. The hospitals ranged in size from 82 to 715 beds. Those currently smoking were automatically referred to one of two tobacco treatment options: 1) Enhanced care (EC) where patients could receive a bedside consult by a trained tobacco treatment specialist plus an automated post-discharge follow-up call designed to connect those smoking to the South Carolina Quitline (SCQL); or 2) Basic care (BC) consisting of the post-discharge follow-up call only. An attempt was made to survey patients at 6-weeks after hospitalization to assess smoking status.ResultsSmoking prevalence ranged from 14 to 49% across the six hospitals; 6,000 patients were referred to the TTP.The delivery of the bedside consult varied across the hospitals with the lowest in the Charleston hospitals which had the highest caseload of referred patients per specialist. Among patients who received a consult visit during their hospitalization, 50% accepted the consult, 8% opted out, 3% claimed not to be current smokers, and 38% were unavailable at the time of the consult visit. Most of those enrolled in the TTP were long-term daily smokers.Forty-three percent of patients eligible for the automated post-discharge follow-up call answered the call, of those, 61% reported smoking in the past seven days, and of those, 34% accepted the referral to theSCQL. Among the 986 of patients surveyed at 6-weeks after hospitalization quit rates ranged from 20%-30% based on duration of reported cessation and were similar between hospitals and for patients assigned to EC versus BC intervention groups.ConclusionFindings demonstrate the broad reach of an opt-out TTP. Elements of treatment delivery can be improved by addressing patient-to-staffing ratios, improving systems to prescribe stop smoking medications for patients at discharge and linking patients to stop smoking services after hospital discharge.

Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis

Acute biliary pancreatitis (ABP) with cholangitis requires endoscopic retrograde cholangiopancreatography (ERCP) within 24 h to resolve ductal obstruction. However, this recommendation is based on the timing of emergency room (ER) visits. We wanted to determine the optimal timing of ERCP for ABP based on the timing of symptom onset, not the timing of the ER visit. We retrospectively reviewed 162 patients with ABP with cholangitis who underwent urgent ERCP (within 24 h of ER admission). Area under the receiver operating characteristic (ROC) curve (AUC) was analyzed to determine differences in complication rates according to time from symptom onset. A difference in ERCP-related adverse events (AEs) was identified, and Youden’s J statistic was used to determine a cutoff time from symptom onset (18 h). We compared mortality and complications based on this cutoff. Based on time to symptom onset, significantly higher rates of aspiration pneumonia (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.15–13.92, P = 0.021) and post-ERCP hypotension (OR 11.9, 95% CI 1.39–101.33, P = 0.005) were observed in the ≤ 18-h group than in the > 18-h group. The study found that patients who underwent ERCP within 18 h of symptom onset is associated with an increased risk of ERCP-related AEs.

Enhancing traumatic brain injury emergency care: the impact of grading and zoning nursing management

ABSTRACT Objective This research aimed to evaluate the impact of grading and zoning nursing management on traumatic brain injury (TBI) patients’ emergency treatment outcomes. Methods This randomized controlled trial included 200 TBI patients. They were treated with a conventional care (control group, n = 100) and a novel grading and zoning approach (study group, n = 100), respectively. This innovative model organized care into levels based on urgency and complexity, facilitating targeted medical response and resource allocation. Key metrics compared included demographic profiles, consultation efficiency (time metrics and emergency treatment rates), physiological parameters (HR, RR, MAP, SpO2, RBS), and patient outcomes (hospital and ICU stays, complication rates, and emergency outcomes). Results The study group demonstrated significantly improved consultation efficiency, with reduced times for physician visits, examinations, emergency stays, and specialist referrals (all p < 0.001), alongside a higher emergency treatment rate (93% vs. 79%, p = 0.004), notably better physiological stability, improved HR, RR, MAP, SpO2 and RBS (p < 0.001), shorter hospital and ICU stays, fewer complications, and superior emergency outcomes. Conclusion Grading and zoning nursing management substantially enhances TBI patients’ emergency care efficiency and clinical outcomes, suggesting a viable model for improving emergency treatment protocols.

Emergency department utilization by persons with rheumatoid arthritis: a population-based cohort study

Some emergency department (ED) visits by persons with rheumatoid arthritis (RA) may be avoidable. This study aims to describe ED use by persons with RA in Alberta, Canada over a 10-year period. Using linked population-based administrative datasets, the annual frequency of ED visits, timing of visits, acuity at presentation assessed (Canadian Triage Acuity Scale (CTAS)), return visits within 72 h, and final disposition were assessed. Most responsible diagnoses assessed by the ED provider were categorized. Between 2008 and 2017, a total of 48,633 persons with RA had 416,964 unique ED visits. There was a 41% relative increase in visits over the study period and within a fiscal year 37% of persons with RA on average attended an ED. Half of the visits were assessed as CTAS 4 ‘Less Urgent’ (31%) and CTAS 5 ‘Non-Urgent’ (19%). No specific diagnosis could be assigned in 36% of visits and RA was listed as the most responsible diagnosis in 2.5% of all visits. Hospital admissions, occurring on average for 14% of ED visits, increased by 15% over the 10 years, and were rare for CTAS 4 (6.4%) and CTAS 5 (1.4%) presentations. Male patients (difference to female 1.2%, 95%CI 0.6, 1.7) and urban patients (difference to rural 8.4%, 95%CI 7.7, 9.2) were more frequently admitted to hospital. Persons with RA have increased ED utilization over time, with a significant volume of less urgent and non-urgent visits. Opportunities for appropriate ambulatory care provision to reduce acute care use should be identified.

Well-Child Visits for Early Detection and Management of Maternal Postpartum Hypertensive Disorders

Innovative approaches are needed to address the increasing rate of postpartum morbidity and mortality associated with hypertensive disorders. To determine whether assessing maternal blood pressure (BP) and associated symptoms at time of well-child visits is associated with increased detection of postpartum preeclampsia and need for hospitalization for medical management. This is a pre-post quality improvement (QI) study. Individuals who attended the well-child visits between preimplementation (December 2017 to December 2018) were compared with individuals who enrolled after the implementation of the QI program (March 2019 to December 2019). Individuals were enrolled at an academic pediatric clinic. Eligible participants included birth mothers who delivered at the hospital and brought their newborn for well-child check at 2 days, 2 weeks, and 2 months. A total of 620 individuals were screened in the preintervention cohort and 680 individuals were screened in the QI program. Data was analyzed from March to July 2022. BP evaluation and preeclampsia symptoms screening were performed at the time of the well-child visit. A management algorithm-with criteria for routine or early postpartum visits, or prompt referral to the obstetric emergency department-was followed. Readmission due to postpartum preeclampsia. Comparisons across groups were performed using a Fisher exact test for categorical variables, and t tests or Mann-Whitney tests for continuous variables. A total of 595 individuals (mean [SD] age, 27.2 [6.1] years) were eligible for analysis in the preintervention cohort and 565 individuals (mean [SD] age, 27.0 [5.8] years) were eligible in the postintervention cohort. Baseline demographic information including age, race and ethnicity, body mass index, nulliparity, and factors associated with increased risk for preeclampsia were not significantly different in the preintervention cohort and postintervention QI program. The rate of readmission for postpartum preeclampsia differed significantly in the preintervention cohort (13 individuals [2.1%]) and the postintervention cohort (29 individuals [5.6%]) (P = .007). In the postintervention QI cohort, there was a significantly earlier time frame of readmission (median [IQR] 10.0 [10.0-11.0] days post partum for preintervention vs 7.0 [6.0-10.5] days post partum for postintervention; P = .001). In both time periods, a total of 42 patients were readmitted due to postpartum preeclampsia, of which 21 (50%) had de novo postpartum preeclampsia. This QI program allowed for increased and earlier readmission due to postpartum preeclampsia. Further studies confirming generalizability and mitigating associated adverse outcomes are needed.

Identifying factors underlying increased emergency care needs of Black patients with pancreas cancer.

e13749 Background: In a retrospective study, we observed that African American/Black patients are 2.8x more likely to have recurrent ED visits than non-Black patients. These findings motivated this prospective study using a standardized questionnaire to better understand the factors leading to ED visits among Black patients. Methods: A study of Black patients with pancreas cancer who had at least 1 ED visit in a 5 month period in 2022-2023 was conducted. Computational identification of health system encounters by patients with pancreas cancer was performed using ICD10 C25* as a cohort identifier. The cohort was filtered by encounter type for ED and self-reported race for Black. Weekly, an African American oncology nurse practitioner called these patients to administer a questionnaire regarding social determinants of health and discuss reasons underlying the ED visit. Three attempts were made to contact each patient. Demographic and clinical features were obtained from the electronic health record. Results: During this 5-month period, 31 patients meeting criteria were identified; among these 31 who had at least 1 ED visit, 45% had ≥2 ED visits and 13% had ≥5 ED visits. The cohort was 68% female with mean age of 70.3 and median household income of $92,608. 74% had non-metastatic disease and 35% were on chemotherapy at the time of visit. 52% of patients had Medicare, 35% had commercial insurance, 10% had Medicaid, and 3% were uninsured. We reached 55% patients, of whom 71% agreed to participate. Notably, 83% endorsed high school as their highest level of education, 25% were immigrants to the United States, and 17% experienced financial barriers to care (Table). 33% had been seen at our institution’s pancreas cancer multidisciplinary clinic. Two recurrent themes noted during discussions with these patients were that that those with multiple ED visits were nearing end-of-life and/or had caretakers or family members in the medical field. Conclusions: We identified female gender, education level, immigrant status, and financial barriers to care as themes associated with ED visit burden in Black patients with pancreas cancer. Having caretakers in the medical field, who may have witnessed the consequences of healthcare disparities, may also contribute to higher rates of ED use. We hope to use these data to inform interventions to address these disparities. [Table: see text]

Predictors of symptom scores in myeloproliferative neoplasms: A real-world retrospective cohort study.

6582 Background: Although high symptom burden indicates poor survival and informs treatment decisions, little is known about the impact of demographic, clinical, and laboratory features on total symptom score (TSS) in patients with myeloproliferative neoplasms (MPN). Methods: Patients with MPN (polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF)) were identified from the retrospective chart review. TSS, individual symptom scores (fatigue, early satiety, abdominal discomfort, inactivity, concentration problems, fever, night sweats, itching, bone pain, weight loss), demographic characteristics (race, ethnicity, age, gender), clinical features (time since diagnosis, depression status, obesity status, spleen size), laboratory results and season at the time of visit were recorded from the clinical encounter when index assessment of TSS was performed for each patient. Normality was assessed using visual inspection of data distribution, whereas multicollinearity was assessed using various inflation factors. A univariable regression followed by a multivariable regression analysis was conducted using a backward selection approach. A p-value &lt;0.05 indicated a statistically significant association of a given feature with TSS. Results: The chart review identified 252 patients (PV: 78; ET: 81; MF: 93). Mean age was 59 (SD: 17.7), 67 (SD: 13.0), and 68 (SD: 10.9) years for ET, PV, and MF respectively. Most patients were white (PV, MF: 92%; ET: 83%) and females (ET: 75%; PV: 60%; MF: 53%). The TSS of patients was highest with PV (mean: 18.5; SD: 16.9) followed by MF (mean: 18.1; SD: 15.4) and ET (mean: 14.3; SD: 15.9). Fatigue was the most reported symptom whereas the least reported symptoms were fever and weight loss. Univariable regression analyses showed depression (B: 17.7; p=0.02), female gender (B: 10.6; p=0.01), platelet count (B: 0.03; p=0.03), and hemoglobin (Hb) (B: -2.6; p=0.01) in PV patients, depression (B: 19.8, p=2x10-5) in ET patients and depression (B: 11.0, p=0.03), white blood cell (WBC) count (B: 0.2; p=0.01), neutrophil count (B: 0.3, p=0.01), and non-neutrophil WBC count (B: 0.6; p=0.02) in MF patients to have significant association with TSS. Multivariable regression analyses ( Table) showed Hb (B: -2.5; p=0.01) and platelet count (B: 0.02; p=0.03) in PV patients, depression (B: 19.7; p=2x10-5) in ET patients and depression (B: 12.3, p=0.01) and WBC count (B: 0.3; p=0.002) in MF patients to have a significant association with TSS. Conclusions: Depression in ET and MF and low Hb in PV were identified as significant drivers of symptom burden. Identifying and managing patients with these comorbidities could improve their quality of life with a potential survival benefit. [Table: see text]

Real-world evaluation of oncolytic biosimilar adoption on medication adherence and out-of-pocket costs among members of a national payor.

e23092 Background: Biosimilars provide quality, safe, effective, and lower-cost alternative treatment options that have no difference from their reference product. CVS Health® recently launched a biosimilar adoption strategy to expand access to biosimilars and drive sustainable cost savings and options for consumers. The purpose of this study is to compare treatment duration, adherence, and out-of-pocket (OOP) costs between individuals receiving oncology biosimilars versus oncology reference branded products. Methods: This retrospective cohort study included adult commercial fully insured and Medicare members of a large national payor with ≥1 claim for a physician-administered oncology biosimilar or reference branded product between 12/01/2020 and 11/30/2022. To assess adherence, we compared claims per month, defined as the total claims during the study divided by the number of months patients received medication and time on therapy, defined as the number of months between first claim in period and last claim in period (inclusive). OOP costs, defined as the sum of deductible and applicable coinsurance at the time of visit, were examined as a secondary endpoint. Continuous variables were compared with Student’s t-test; categorical variables were compared with a Chi-squared test. P values &lt; 0.05 were considered significant. Results: 2,597 individuals were included in the evaluation with between-group differences in age, gender, and agent received (all p &lt; 0.001). 41,182 claims were evaluated; 59.2% were for reference branded products. 3,817 medication combinations were evaluated; 64.2% received a reference branded product. Individuals receiving biosimilar agents had more total claims (mean [standard deviation, SD]: 13.9 [6.3] vs. 13.1 [7.5]; p = 0.003) and claims per month (1.4 [0.5] vs. 1.3 [0.6]; p &lt; 0.001). However, individuals receiving reference branded products had longer time on therapy (10.5 [4.1] vs. 10.0 [3.7] wk; p = 0.006). When examining oncology agents only (n = 1,992), individuals receiving biosimilar agents had more claims per month (1.4 [0.5] vs. 1.3 [0.6]; p &lt; 0.001). In contrast, individuals receiving reference branded products had longer time on therapy (11.0 [4.1] vs. 10.1 [3.7] wk; p &lt; 0.001). Individuals prescribed oncology support reference branded products and oncology treatment reference branded products experienced 475% and 350% higher OOP spend compared to individuals prescribed biosimilars (both p &lt; 0.001), respectively. Conclusions: This real-world evaluation leveraging administrative claims revealed that individuals receiving oncology biosimilars appear to experience shorter observed time on therapy, higher adherence, and lower OOP spend than individuals receiving reference branded products. Despite superior member-centric outcomes, reference branded products were prescribed more often than biosimilars.

Improving primary health care for children and adolescents in Europe

Primary health care for children in Europe is often not optimal. Primary care providers might not have been trained adequately in dealing with common conditions affecting children and adolescents, and outdated practices often persist. To address these problems, WHO developed the Pocket Book of Primary Health Care for Children and Adolescents. It is for use by doctors, nurses and other health workers who are responsible for the care of children and adolescents at the primary health care level. It summarizes guidance on how to manage – and when to refer – children and adolescents presenting with common complaints and conditions. It includes information to enable primary health care providers to coordinate the continued care of children and adolescents with long-term conditions and diseases managed by specialists. Preventive and promotive measures from the newborn period to adolescence include advice on the timing and content of well-child visits, the promotion of early childhood development and health messages for adolescents.The recommendations of the Pocket Book apply across the WHO European Region and may be adapted by countries to suit their specific circumstances. A mobile APP for Android and IOS phones is available to facilitate uptake and dissemination. The Pocket Book and APP aim to improve quality of care for children and adolescents at the primary health care level. Quality of care is at the core of the comprehensive European Child and Adolescent Health Strategy that is being developed by Member States supported by WHO and partners to refocus attention on child and adolescent health after the COVID-19 pandemic had scooped attention and resources away from this age group. Countries are encouraged to adapt Pocket Book and Strategy to improve the situation of child and adolescent health and well-being in their settings and monitor progress.

INUDGE: Integration of liquid biopsy based next generation gene sequencing in newly diagnosed NSCLC—A stepped wedge cluster randomized clinical trial.

TPS8664 Background: The development of targeted therapies has changed the treatment paradigm for non–small cell lung cancer (NSCLC). With the growing number of FDA approved targeted therapies, current NCCN guidelines recommend comprehensive molecular genotyping prior to first line (1L) therapy for all newly diagnosed patients with metastatic non-squamous (mNSq) NSCLC to enable the delivery of personalized therapy. Based on prior work that found improved detection of clinically actionable alterations through concurrent plasma (P) based next-generation gene sequencing (NGS) and tissue NGS, we piloted a behavioral economics (BE) informed electronic health record (EHR)-based “nudge” intervention designed to facilitate P NGS at the new patient medical oncology visit. After implementing across 3 practices within the University of Pennsylvania Health System (UPHS), our findings demonstrated that EHR-based nudges are feasible and can promote guideline concordant diagnostic testing at both community and academic sites (1). Methods: Design: NCT05853887 is a prospective stepped wedge cluster randomized trial that includes 3 “clusters”, representing 6 community-based cancer centers. The primary objective of this trial is to test the effectiveness of a BE informed EHR nudge intervention to increase availability of comprehensive molecular test results before 1L therapy by incorporating concurrent tissue and plasma-based molecular testing. Secondary objectives include evaluation of contextual mechanisms contributing to the adoption, reach, and effectiveness of EHR nudge interventions with a lens for health equity. Intervention: An EHR-based nudge that allows for default order placement of P NGS testing at the time of the first medical oncology visit will be implemented. Subsequently, results detected on the default P NGS order will be conveyed to providers in the form of an electronic clinical decision support notification. Statistical Methods:Sample size is based on estimates of the proportion of patients undergoing comprehensive molecular testing prior to 1L. A sample of 3 clusters in a complete stepped-wedge cluster-randomized design with 4 time periods (including the baseline), 3 steps, 1 cluster(s) switching from control to treatment at each step, and an average of 120 subjects per cluster with an average of 30 subjects per cluster per time period (for a total sample size of 360 subjects) will provide 80% power to detect a difference between proportions of 0.21701. Patients with histological, or cytological diagnosis of Stage IV mNSq NSCLC who have not yet received systemic treatment for metastatic disease are eligible for inclusion. Enrollment is ongoing: Cluster 1 began enrollment in June 2023, Cluster 2 in October 2023, and Cluster 3 is planned for February 2024. 1. Aggarwal C et al, JCO, Vol 40, Num 16, Suppl Jun 2022. Clinical trial information: NCT05853887 .

Glioma monitoring via longitudinal intracranial cerebrospinal fluid cell-free DNA.

2053 Background: Current methods for glioma treatment response assessment are limited. This study aimed to assess the technical and clinical feasibility of molecular profiling using intracranial CSF from patients with gliomas during their disease course. Methods: Adults with gliomas were recruited for longitudinal intracranial CSF collection using 1) Ommaya reservoirs, from which CSF would be sampled on at least two separate occasions, or 2) CSF collection from other clinically indicated CSF access devices, such as ventriculoperitoneal (VP) shunts. Patients were followed until their last visit or present time for ongoing participants. For this initial cfDNA feasibility study, CSF was collected from Ommaya reservoirs in four patients and from an existing VP shunt in one patient. cfDNA was then extracted and analyzed using two sequencing platforms, PredicineCARE for cancer variant profiling and PredicineSCORE for low-pass whole genome sequencing (LP-WGS). This analysis generated genomic aberration profiles and genome-wide copy number burden (CNB) score. Results: Five patients (2 females, 3 males; median age: 40 years, range 32-64 years) underwent longitudinal intracranial CSF collection via Ommaya reservoirs (n=4) or VP shunt (n=1). In total, thirty-five CSF samples were obtained (median volume: 3.80 mL; 0.5-5 mL), with 30 samples (85.7%) yielding sufficient cfDNA for variant profiling and LP-WGS. Our initial findings suggest that tumor fraction increased by 6.28x and 2.87x with radiographic progression in two patients. Tumor fraction decreased by 0.08x and 0.04x in two patients with paired immediate pre-versus-post chemoradiation samples. Despite ongoing pseudoprogression in one patient, tumor fraction decreased to unmeasurable levels from a post-resection baseline of 0.26. Patient-specific tumor-associated variant allelic frequencies (VAFs), including TP53, PTEN, TERT, and CDKN2A/B, decreased within individual patients after resection and chemoradiation. In two patients with isocitrate dehydrogenase (IDH) mutant gliomas, decreasing IDH1 VAF after resection correlated with decreased CSF D-2-hydroxyglutarate (D-2-HG) levels (0.64x and 0.62x, respectively, for the first patient, and 0.01x and 0.07x for the other patient). Both CSF IDH1 VAF and CSF D-2-HG increased in the patient who had radiographic progression (2.56x and 9.21x, respectively). Moreover, CNB decreased below the limit of quantification during treatment and increased above the limit at progression. Conclusions: Longitudinal CSF cfDNA can feasibly be obtained via CSF access devices in patients with gliomas during their disease course. Ongoing studies will evaluate hypotheses generated in this case series regarding how longitudinal CSF cfDNA could be utilized to sensitively detect changes in disease burden. Clinical trial information: NCT04692337 ; NCT04692324 .

Clinicians' perspectives of barriers and facilitators of suicide screening in head and neck cancer care.

e18023 Background: Patients with head and neck cancer (HNC) face a heightened risk of suicide, surpassing rates in other cancers and the general population. Unfortunately, there are currently no suicide-specific clinical guidelines in oncology, and it is unclear what barriers and facilitators impact suicide screening initiatives in HNC care. This qualitative study explored experiences, barriers and facilitators of suicide screening and management of mental health concerns in a diverse group of HNC clinicians. Methods: We conducted qualitative interviews with 16 HNC clinicians at a single healthcare system, including head and neck surgeons, radiation oncologists, medical oncologists, and nurses/nurse practitioners/physician assistants. Interviews covered topics such as clinicians’ perspective of the impact of HNC on patients’ mental health, experience with suicide risk assessment, existing protocols, and overall experiences related to managing mental health concerns in patients with HNC. Using rapid analysis techniques, we identified common challenges, facilitators, and training needs. Results: Our study uncovered distinct barriers faced by HNC clinicians. Key themes included the notable absence of formal suicide and mental health training among HNC clinicians; critical gaps in clinician education and the lack of established protocols for appraising and managing mental health concerns, particularly those related to suicide risk. Other barriers identified included clinicians’ uncertainties in recognizing and addressing suicidal thoughts, limited familiarity with available screening tools, and insufficient resources for patient support. Some key facilitators also emerged, including longer clinic visit times, mental health discussions in interdisciplinary conferences, and greater accessibility of mental health services for comprehensive patient support. Conclusions: In this qualitative study, we observed important barriers in mental health support and service delivery for HNC patients, especially gaps in clinician training, and lack of knowledge of existing suicide-related protocols. Given the suicide burden in HNC, it is important to address these challenges and begin developing initiatives for clinician training and formalized protocols to enhance mental health care for HNC patients.

Exploring Oral Health Knowledge and Practices among Early Childhood Caregivers A Cross-Sectional Survey

Early childhood is a crucial developmental phase of a child's well-being, which lays the foundation for their future growth. Lack of good oral practices may cause dental issues during this fundamental phase of development and have a long-lasting impact on a child's overall well-being. This cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan, to explore oral health knowledge and practices among the caregivers of young children. A sample of 94 participants, including parents, caregivers, early childhood educators, and healthcare professionals (HCPS), was included through a convenient sampling technique. An online survey questionnaire was administered, which covered various aspects of oral hygiene practices to prevent common oral diseases among children. All statistical analyses were performed using SPSS 22.0. Statistical significance was accepted as p ≤0.05. Results of the study revealed no significant differences in oral health knowledge and practices based on age and gender. However, comparisons based on profession and roles showed a significant difference. Most participants agreed on the importance of regular oral hygiene practices. However, their opinions differed on certain oral hygiene practices, including the frequency of brushing and the timing of the first dental visit. This study underscores the importance of targeted education and interventions to improve oral health outcomes during the critical developmental phase of childhood.

Long-term, Low-Dose Oral Azithromycin Treatment for Chronic Severe Bilateral Blepharokeratoconjunctivitis in Pediatric Patients.

To evaluate the efficacy and safety of oral azithromycin treatment combined with topical antibiotic and anti-inflammatory agents in pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis. Patients younger than 14 years with chronic and severe bilateral blepharokeratoconjunctivitis were reviewed retrospectively. Consecutive patients receiving oral azithromycin treatment were included. All patients received oral azithromycin (5 mg/kg/single dose daily) for at least 4 weeks combined with topical antibiotic and anti-inflammatory agents. Before and after the treatment, clinical symptoms were noted, and corneal and conjunctival fluorescein staining and corneal neovascularization were graded. Meibomian gland secretion and meibomian gland plugging were also assessed. All patients completed at least 3 months of follow-up after completion of the oral azithromycin treatment. Patients' clinical data at the time of diagnosis and last follow-up visit were statistically compared. Twenty-nine children (58 eyes, mean age of 6.51 years) were included. The mean time of oral azithromycin use was 5.87 weeks (range: 4 to 10 weeks). Clinical symptoms and signs and visual acuity were significantly improved after treatment. The mean fluorescein staining and corneal neovascularization grades and meibomian gland secretion and meibomian gland plugging scores also improved after treatment (P < .001). Eyelid distortion or fornix shortening was not observed. At the last follow-up visit, all patients were stable with treatment only with daily eyelid hygiene, topical cyclosporine, and artificial tears. Long-term, low-dose oral azithromycin combined with topical antibiotic and anti-inflammatory agents is an effective treatment option for pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

A large cryptosporidiosis outbreak associated with an animal contact event in England: a retrospective cohort study, 2023.

Development of gastrointestinal illness after animal contact at petting farms is well described, as are factors such as handwashing and facility design that may modify transmission risk. However, further field evidence on other behaviours and interventions in the context of Cryptosporidium outbreaks linked to animal contact events is needed. Here, we describe a large outbreak of Cryptosporidium parvum (C. parvum) associated with a multi-day lamb petting event in the south-west of England in 2023 and present findings from a cohort study undertaken to investigate factors associated with illness. Detailed exposure questionnaires were distributed to email addresses of 647 single or multiple ticket bookings, and 157 complete responses were received. The outbreak investigation identified 23 laboratory-confirmed primary C. parvum cases. Separately, the cohort study identified 83 cases of cryptosporidiosis-like illness. Associations between illness and entering a lamb petting pen (compared to observing from outside the pen; odds ratio (OR)=2.28, 95 per cent confidence interval (95% CI) 1.17 to 4.53) and self-reported awareness of diarrhoeal and vomiting disease transmission risk on farm sites at the time of visit (OR=0.40, 95% CI 0.19 to 0.84) were observed. In a multivariable model adjusted for household clustering, awareness of disease transmission risk remained a significant protective factor (adjusted OR (aOR)=0.07, 95% CI 0.01 to 0.78). The study demonstrates the likely under-ascertainment of cryptosporidiosis through laboratory surveillance and provides evidence of the impact that public health messaging could have.

Association of COVID-19 and the Prevalence of In-person Versus Telehealth Primary Care Visits and Subsequent Impacts on Tobacco Use Assessment and Referral for Cessation Assistance.

The COVID-19 pandemic dramatically altered patterns of healthcare delivery. Smoking remains an important risk factor for multiple chronic conditions and may exacerbate more severe symptoms of COVID-19. Thus, it is important to understand how pandemic-induced changes in primary care practice patterns affected smoking assessment and cessation assistance. Electronic health record data from eight community health centers were examined from March 1, 2019 to February 28, 2022. Data include both telehealth (phone and video) and in-person office visits and represent 310 388 visits by adult patients. Rates of smoking assessment, provision of referral to counseling, and orders for smoking cessation medications were calculated. Comparisons by visit mode and time period were examined using generalized estimating equations and logistic regression. The proportion of telehealth visits was < 0.1% 1 year prior to COVID-19 onset and, 54.5% and 34.1% 1 and 2 years after. The odds of asking about smoking status and offering a referral to smoking cessation counseling were significantly higher during in-person versus telehealth visits; adjusted odds ratios (AOR) (95% CI) = 15.0 (14.7 to 15.4) and AOR (95% CI) = 6.5 (3.0 to 13.9), respectively. The interaction effect of visit type * time period was significant for ordering smoking cessation medications. Telehealth visits were significantly less likely to include smoking status assessment and referral to smoking cessation counseling compared to in-person visits. Given that smoking assessment and cessation assistance do not require face-to-face interactions with health care providers, continued efforts are needed to ensure provision at all visits, regardless of modality. The COVID-19 pandemic dramatically altered patterns of healthcare-seeking and delivery with a considerable rise in telehealth visits. This study examined 1 year prior to the onset of COVID-19 and 2 years after to evaluate the assessment of tobacco use and assistance with tobacco cessation and differences during in-person versus telehealth visits. Tobacco assessment was 15 times more likely during in-person versus telehealth visits in the 2 years post onset of COVID-19. Given that telehealth visits are likely to continue, ensuring that patients are regularly assessed for tobacco regardless of visit modality is an important concern for health systems.

Factors associated with engagement in HIV care for young people living with perinatally acquired HIV in England: An exploratory observational cohort study.

Identifying which young people living with perinatally acquired HIV (PHIV) are less likely to engage in care is crucial to allow targeted interventions to support them to attend clinic. We adapted an existing Engagement in Care (EIC) algorithm for adults with HIV in England, for use in young people. We applied it to data from young people with PHIV in the Adolescents and Adults Living with Perinatal HIV (AALPHI) cohort. The algorithm predicts the timing of the next scheduled clinic visit, within 1-6 months of current visit, based on routine clinical data. Follow-up was 12-months from AALPHI baseline interview. Each person-month was classified as engaged in care or not. Logistic regression models (allowing for clustered data) were used to explore baseline characteristics associated with being engaged in care, adjusting for a priori variables (time from interview, sex, age, ethnicity, country of birth). Potential characteristics were across 7 domains: sociodemographic; risk behaviour practices; mental health; cognition; clinic setting; HIV management and experience; and HIV clinical markers. Of 316 young people, 187(59%) were female, 271(86%) of black ethnicity and 184(58%) born abroad. At baseline, median [IQR] age was 17[15-18] years, and 202(69%) had viral load ≤50 copies/ml(c/mL). 87% of 3,585 person-months were classified as engaged in care. Characteristics independently associated with poorer odds of being engaged in care were: Asian/mixed/other ethnicity, vs. black ethnicity (OR 0.44, 95% CI 0.25, 0.78, p = 0.02); ever self-harmed, vs. not (OR 0.55, 95% CI 0.32, 0.95, p = 0.03); on antiretroviral therapy (ART) and self-assessed bad/not so good adherence (OR 0.46, 95% CI 0.25, 0.84) or not on ART (OR 0.64, 95% CI 0.64, 1.21) vs. on ART and good/excellent adherence (p = 0.04)); baseline VL>50c/mL, vs VL≤50c/mL (OR 0.47, 95% CI 0.30, 0.75, p = 0.002). These characteristics can help identify individuals requiring enhanced support to maintain service engagement.

Extracellular Vesicle - MDM2-DNA as a Potential Liquid Biopsy Biomarker for Disease Identification in Retroperitoneal Liposarcoma.

We aimed to assess the levels of MDM2-DNA within extracellular vesicles (EVs) isolated from the serum of retroperitoneal liposarcoma (RLS) patients versus healthy donors, as well as within the same patients at the time of surgery versus post-operative surveillance visits. To determine whether EV-MDM2 may serve as a possible first-ever biomarker of liposarcoma recurrence. A hallmark of well-differentiated and de-differentiated (WD/DD) retroperitoneal liposarcoma is elevated MDM2 due to genome amplification, with recurrence rates of >50% even after complete resection. Imaging technologies frequently cannot resolve recurrent WD/DD-RLS versus postoperative scarring. Early detection of recurrent lesions, for which biomarkers are lacking, would guide surveillance and treatment decisions. WD/DD-RLS serum samples were collected both at the time of surgery and during follow-up visits from 42 patients, along with sera from healthy donors (n=14). EVs were isolated, DNA purified and MDM2-DNA levels determined through q-PCR analysis. Non-parametric tests were employed to compare EV-MDM2 DNA levels from patients versus control group, as well as the time of surgery versus post-surgery conditions. EV-MDM2 levels were significantly higher in WD/DD-RLS than controls (P= 0.00085). Moreover, EV-MDM2 levels were remarkably decreased in WD/DD-RLS patients after resection (P=0.00036), reaching values comparable to control group (P=0.124). During post-operative surveillance, significant increases of EV-MDM2 was observed in some patients, correlating with CT scan evidence of recurrent or persistent post-resection disease. Serum EV-MDM2 may serve as a potential biomarker of early recurrent or post-operatively persistent WD/DD-RLS, a disease currently lacking such determinants.

Disparities in Patient Portal Engagement Among Patients With Hypertension Treated in Primary Care

Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control. To characterize patient portal use among patients with hypertension managed in primary care. This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders. Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status. Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings. Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73). This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.