Weeks Of Consultation Research Articles

Increased risk of haematological malignancy in adults over age 60 with thrombocytopenia compared with matched controls: Time for an upfront bone marrow evaluation?

International societies have conflicting recommendations on whether bone marrow aspirate/biopsy (BMB) is needed during workup for isolated thrombocytopenia. Our objective was to determine if thrombocytopenia in patients aged ≥60 years is associated with an increased incidence of haematological malignancy. We performed a retrospective population-based cohort study in patients aged ≥60 years between January 1, 2009 to December 31, 2019. Exposed patients had specialist consultation for thrombocytopenia, with platelet count <100 × 109/L, but normal haemoglobin and white blood cell count. Unexposed patients were those who never had specialist consultation for thrombocytopenia and whose platelets were ≥100 × 109/L. The primary outcome was the diagnosis of haematological malignancy using a competing risk of death model. During 4.0 years (IQR 2.2-6.7) of follow-up, 378/4930 exposed (19.1/1000PY, 95% CI 17.1-21.0), and 204/17556 unexposed patients (2.5/1000PY, 95% CI 2.2-2.8) were diagnosed with haematological malignancy (HR 15.5 (95% CI 11.3-21.4, p < 0.0001) in year 1, and 5.3 (95% CI 4.4-6.6, p < 0.0001) in years 2+). This finding persisted in analyses stratified by sex, age, severity, or duration of thrombocytopenia, and treatment with corticosteroids within 2 weeks of consultation. This study found a strong association between isolated thrombocytopenia and haematological malignancy in patients ≥60 years, supporting consideration of diagnostic testing including BMB during outpatient specialist consultation.

Inpatient Simulation Resource Utilization for Inpatient Radiation Oncology Consults

Previous data have shown that inpatient radiation oncology consult services result in high-value care, with decreased length of stay, adoption and delivery of shorter fractionation schedules, and lower hospital costs. As such, institutions are increasingly creating inpatient radiation oncology services, although little is known about the allocation of limited resources for patients who may have limited prognosis, complex simulation requirements, and may have difficulty tolerating treatment. Thus, we sought to examine the utilization of simulation appointments for inpatient emergencies. At our institution, inpatient consults are placed to a specialized inpatient palliative radiation oncology service, consisting of radiation oncologists specialized in metastatic and palliative RT, dedicated advanced practitioners, and nurses who specifically assess patients for medical appropriateness prior to simulation, including changes in disposition, medical stability, and adequate premedication. Electronic health record data was used to explore utilization trends of a single-institution inpatient radiation oncology consult service in 2020. Data regarding the nature and timing of consults, subsequent simulations and treatments, and patient outcomes including 14-day mortality and 30-day mortality from radiation (RT) start were assessed. Descriptive statistics are presented. From 1/1/2020-12/31/2020, 1557 consults were placed. These consults led to 220 (14.1%) inpatient simulations. Of these planned simulations, 210 (95.5%) simulations occurred (of which 10 [4.8%] were rescheduled and eventually completed) and 179 (85.2%) completed treatment. Of 169 with mortality data available, 16 (9.5%) died within 14 days of RT start, and 41 (24.5%) died within 30 days of RT start. Of those with scheduling data (N = 193), 122 were same-day simulations (63.2%), and 507 (93.8%) occurred within 7 days or fewer. Of 1557 inpatient consultations in one year, with appropriate metastatic and palliative experience, only a minority of consultations required inpatient simulation (14.1%). With appropriate nursing assessment, over 95% were able to complete simulation, with nearly two-thirds completing simulation on the same day, and nearly all patients completing simulation within a week of consultation. Most of these patients completed treatment and survived 30 days from treatment start. Thus, with highly specialized radiation oncologist clinical judgment in conjunction with appropriate nursing assessment prior to simulation scheduling, patients booked for simulation represent high-value utilization of resources.

Isolated Thrombocytopenia in Older Adults Is Associated with the Diagnosis of Hematologic Malignancy: A Population-Based Study

Background: In older patients, performing a bone marrow aspirate/biopsy (BM) during consideration of the diagnosis of immune thrombocytopenia (ITP) is controversial, and international hematology societies conflict in their recommendations due to limited evidence. Although ITP is more common in patients older than 60 years, the prevalence of hematologic malignancy also rises with age. The objective of this study was to determine whether isolated thrombocytopenia in patients aged 60 years and older is associated with the diagnosis of a hematologic malignancy, compared to matched patients without thrombocytopenia. Methods: We performed a retrospective population-based propensity-matched cohort study using linked health administrative data in Ontario, Canada. We included patients aged 60 years and older. Exposed patients were those with an internist or hematologist billing a consultation for thrombocytopenia, with laboratory-documented thrombocytopenia (platelet count <100x109/L) within 6 months prior to the consultation date (index date). Unexposed patients were those who never had specialist consultation for thrombocytopenia, who had all platelet counts >100x109/L within 6 months prior to index date. Patients were excluded if they had an abnormal hemoglobin or white blood cell count at index date, or a history of cancer, cirrhosis, or inherited bleeding or coagulation disorder. Exposed and unexposed patients were matched 1:4 on age at index (within 1 year), sex, and a propensity-score (within 0.2 standard deviations). The primary outcome was diagnosis of hematologic malignancy using a competing-risk of death model. The secondary outcome was all-cause death. We performed pre-specified stratified analyses on the primary outcome by age (<80; >80 years), sex, duration of thrombocytopenia prior to specialist consultation (<1; >1 year), severity of thrombocytopenia at index date or closest laboratory test prior to index date (<30x109/L; >30x109/L), and patients treated with corticosteroids (prednisone or dexamethasone) within 2 weeks of index date versus patients not treated with corticosteroids. We also performed pre-specified sensitivity analyses on the primary and secondary outcome to compare hazard ratios (HR) among exposed patients stratified by platelet count on index date or closest platelet count prior to index date (<10x109/L, 10-29x109/L, 30-49x109/L, 50-99x109/L). Results: We matched 4,390 exposed to 17,556 unexposed patients from January 1, 2009 to December 31, 2019. Among exposed patients, 378 (8.6%, 95% CI 7.8-9.5; 19.1/1000 person years (PY), 95% CI 17.1-21.0) were diagnosed with hematologic malignancy over 3.91 years of follow-up, compared to 204 unexposed patients (1.2%, 95% CI 1.0-1.3; 2.5/1000PY, 95% CI 2.2-2.8) over 4.05 years of follow-up. In the first year after consultation, the HR for being diagnosed with a hematologic malignancy was 15.5 (95% CI 11.3-21.4, p<0.0001, Figure 1) in exposed patients compared to unexposed. In subsequent years the HR was 5.3 (95% CI 4.4-6.6, p<0.0001, Figure 1). This relationship persisted in stratified analyses by sex, age, severity or duration of thrombocytopenia, and patients treated with corticosteroids within 2 weeks of consultation. Among exposed patients, the majority of hematologic malignancy diagnoses in the first year after index date were registered within 6 weeks of a BM (88%), while in subsequent years 45% of diagnoses were registered within 6 weeks of a BM. The most common hematologic cancer diagnosed in exposed patients was MDS (31%) (Table 1). Over half of cases of hematologic malignancy found in the exposed cohort would have been immediately actionable with disease-specific therapy. In terms of overall survival, 1,277 exposed patients (29.1%, 95% CI 27.8-30.5; 61.1/1000PY, 95% CI 57.8-64.5) and 3,663 unexposed patients (20.9%, 95% CI 20.3-21.5; 44.7/1000PY, 95% CI 43.3-46.2) died during the follow-up period (HR 1.4; 95% CI 1.3-1.5, p<0.0001). In a sensitivity analysis, there was no difference in the rate of hematologic malignancy diagnosis or rate of death based on severity of thrombocytopenia. Conclusions and Relevance: This population-based study demonstrates a strong association between thrombocytopenia and hematologic malignancy in patients aged 60 years and older. These data support the use of BM upfront in outpatient specialist consultation for isolated thrombocytopenia in older patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

School Counselor Consultation Effects on Teachers’ Mindfulness, Stress, and Relationships

In this randomized controlled trial, we explored the effects of a combined mindfulness and social/emotional learning (SEL) school counselor consultation intervention. Participants included a diverse sample of 30 secondary educators teaching in Title 1 school districts. Participants received 5 weeks of consultation based on mindfulness and SEL. Results of hierarchical linear regressions revealed statistically significant improvement in teachers’ mindfulness disposition of acting with awareness. Further, results indicated a practically significant decrease in teacher-reported stress and conflict in the student–teacher relationship. We discuss implications for offering direct services to teachers through consultation with school counselors as a way of providing indirect services to students. Results of this study illustrate how teachers might benefit from school counselor consultation that supports their use of mindfulness strategies and SEL skills in coping with the demands of teaching and in building relationships with students.

What is the rate of COVID-19 infection in a population seeking oral health care?

BackgroundAlthough rates of COVID-19 have remained low among US dentists, the authors aimed to determine the risk of there being COVID-19 in patients seeking oral health care. MethodsThe authors performed a retrospective chart review of all emergency department consultations from June 1, 2020, through December 31, 2020. They used Pearson correlation coefficients to compare rates with citywide prevalence (P < .05). ResultsThe authors located 203 encounters with 149 tests and 10 cases of COVID-19. Cases were strongly correlated with the citywide positivity rate (r = 0.9147; P = .0039). All patients who tested positive were asymptomatic and afebrile, and one-half (50%) visited a dentist within a week of consultation. ConclusionsThe rate of COVID-19 in a population seeking oral health care reflects the community positivity rate. Asymptomatic or presymptomatic patients pose risks to providers, staff members, and other patients. Practical ImplicationsDentists should remain vigilant during the ongoing COVID-19 pandemic, even with vaccination rollout. The Centers for Disease Control and Prevention maintains an accessible website with easy access to each state’s positivity rate and caseload.

Delay in diagnosis of tuberculosis and related factors from a district in Kerala, India

BackgroundEarly diagnosis and treatment of tuberculosis is of vital importance both to cure patients and to reduce transmission for effective control of tuberculosis, It is important to know whether tuberculosis is diagnosed in time and also what causes delay if any. ObjectivesThe study was conducted with the objective of knowing the time taken to diagnose tuberculosis from the onset of symptoms and to identify the causes for delay if any. MethodsA study was conducted in the District of Malapppuram Kerala, South India among newly diagnosed smear positive tuberculosis patients. 489 patients were interviewed soon after diagnosis and their socio-demographic characteristics and details from onset of symptoms to diagnosis were collected using a structured format. ResultsThe mean time taken by the patient for consultation after onset was 36 days and the mean time for diagnosis was 42 days and total time until diagnosis was 78 days. 72.8% patients consult within 6 weeks of onset and 74.7% are diagnosed within 6 weeks of consultation. The delay for diagnosis was more with private institutions. Diagnosis took less time when government facilities are consulted and when cough was a prominent symptom. Socio demographic factors are seen not affecting the time. ConclusionsThere is delay in diagnosing tuberculosis especially with private health providers and more efforts are required to reduce the same.

Patients preference in receiving phone call from oncologist after cancer diagnosis and before in person consultation.

e18044 Background: Diagnosis of cancer creates an emotionally challenging time for patients. Waiting period between receiving diagnosis, and formal consultation with an Oncologist is associated with fear, shock, and uncertainty. Understanding patients’ preferences during this sensitive period is essential in providing high quality care. We hypothesized that receiving a call from an Oncologist, while waiting for a formal consultation, would help patients cope with cancer diagnosis. Methods: To assess our hypothesis, we surveyed 171 patients across five Kaiser Permanente medical centers. All patients received a call from an Oncology navigator to onboard them, and assure completion of necessary tests before in-person consultation with Oncologist. Of the 171 patients surveyed, 61 patients received an additional call from their assigned Oncologist before a formal in-person consultation. To understand the impact of the call made by the Oncologist, a survey was administered to patients within a few weeks of consultation. The remaining 110 patients who only received a call from an Oncology navigator were also surveyed to determine if a call from an Oncologist before their consultation could have helped them cope better with their cancer diagnosis. Results: Approximately 45 % of surveyed patients (n = 171) preferred a call from an Oncologist before the formal consultation. Conclusions: Brief telephone contact by Oncologist before in-person consultation supports newly diagnosed cancer patients with high-levels of uncertainty and shock. A substantial portion of newly diagnosed cancer patients prefers to speak with an Oncologists in the days after receiving a cancer diagnosis, and those who do receive an Oncologist call, find it beneficial in coping with their diagnosis.[Table: see text]

Understanding the non-curative potential of palliative chemotherapy: Do patients hear what they want to hear?

6575 Background: Misconceptions about the curative potential of PC are common, and may arise from gaps in informed consent. Another contributing factor could be patients’ desire, or lack of desire, for information about prognosis and PC outcomes. Methods: We surveyed 137 patients with advanced colorectal (N = 102) or pancreatic cancer (N = 35) within 2 weeks of consultation about 1st or 2ndline PC, as part of randomized trial of a PC education intervention at 6 US sites. Patients rated how much information they wanted about PC risks/benefits, including impact on prognosis. Responses ranged from no information to as much as possible on a 5-point Likert scale. They reported decision-making preferences; whether a doctor discussed curability, and how likely they thought PC was to cure their cancer. Chi square and Wilcoxon tests examined whether information and decision-making preferences, or curability discussions were associated with expectations of cure. Multivariable logistic regressions evaluated whether associations were modified by age, race, gender, marital status, or cancer type. Results: Only 44.5% of patients accurately reported that their cancer was not at all likely to be cured by PC. Most patients wanted a lot, or as much information as possible about PC risks/benefits, including likelihood of cure (81.7%), cancer control (84.7%), and impact on length of life (80.3%). Most patients preferred shared (70.8%) versus active or passive decision-making. Neither decision-making nor prognostic information preferences were associated with expectations of cure. Patients (13.9%) who did not recall curability discussions were less likely to have accurate expectations (21% v 48%; OR, 0.29; 95% CI, 0.07-.97). Patient characteristics did not significantly confound this association. Conclusions: Most patients value shared decision-making and want maximal information about PC risks/benefits, including impact on prognosis. Despite wanting prognostic information and reporting curability discussions, many patients report inaccurate expectations about cure from PC. Future studies should examine whether these assertions reflect misunderstandings, differences in belief, or expressions of hope.

Adapting Parent–Child Interaction Therapy to Foster Care

Objective: This study presents outcomes from a randomized trial of a novel Parent-Child Interaction Therapy (PCIT) model for foster families. Differential effects of two intervention doses on child externalizing and internalizing symptoms are examined. Method: A sample of 102 foster children was assigned to one of three conditions—brief PCIT, extended PCIT, or wait-list control. The brief and extended groups received 2 days of PCIT training and 8 weeks of telephone consultation. The extended PCIT group received an additional booster training plus 6 more weeks of consultation. Wait-list controls received services as usual. Tests of change over time were estimated using mixed-model repeated measures analysis of covariance. Results: Compared to controls, children in both PCIT groups exhibited a greater reduction in externalizing and internalizing scores over time. Pairwise contrasts of the two PCIT conditions yielded mixed results. Conclusion: Results indicate that PCIT can be tailored efficaciously for foster families using alternative treatment modalities.

Tonsillectomy

To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. Five secondary care UK otolaryngology departments. Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.

Use of unnecessary medications by terminally ill cancer patients.

9073 Background: Cancer patients at the end of life take many medications but the proportion who take unnecessary medications(UnM) is unknown. Methods: Cross-sectional survey of medications utilized by terminally ill ambulatory patients with solid tumors. Categorization of the medications as necessary or unnecessary as per criteria developed by the authors, summarized in the Table. Results: Among 87 patients taking a median of 4 (range: 1-13) medications, 21 (24%, 95% CI 15.6–34.5%) were taking at least one UnM, with the most common being gastric protectors (11 instances). Most UnM had been prescribed by physicians, did not determine either cost or adverse events to patients and their median time of use was 240 days (one month to 15 years); the median time of use of necessary medications was 180 days. In multivariable analyses, patients with Charlson Comobidity Index ≤1 (OR: 4.49, CI95% 1.32–15.26; p = 0.01) and those whose medication list had not been reconciled by physicians in the last visit (OR: 6.38, CI95% 1.21–33.40; p = 0.02) were significantly more likely to use an UnM. Conclusions: Patients with terminal cancer take many medications considered unnecessary. Medication reconciliation should be routinely performed by health professionals involved in the care of these patients. Criteria to define UnM Drug class Clinical situation Rational Statins Indication: hypercholesterolemia, but no cardiovascular event in the prior 12 months. The long-term benefit of statins not likely to be seen within 6 months of expected survival Gastric protectors No medical history of gastrointestinal bleeding, peptic ulcer, gastritis or known chronic use (more than 30 days) of anti-inflammatory agents None of the widely accepted indications Antihypertensives Arterial blood pressure < 90 × 60 mmHg at the time of last consultation and symptoms of hypotension Considered dangerous to patients Antidiabetic Either a single measure of fasting glucose < 50 mg/dl within 4 weeks of consultation or reported symptoms of hypoglycemia and a fasting glucose test below lower limit of normal Considered dangerous to patients Any medication No clear medical indication identified Unknown No significant financial relationships to disclose.

Screening older people with musculoskeletal pain for depressive symptoms in primary care.

Older patients presenting to GPs with musculoskeletal pain are at high risk of having concurrent depression. To investigate the performance of ultra-short (1-4 items tools) screening questions used during the consultation, and through a patient questionnaire to detect depressive symptoms among older adults presenting with musculoskeletal pain to general practice. Cross-sectional survey, linked GP consultation data. General practices in central Cheshire, UK. Consecutive patients aged > or =50 years presenting with non-inflammatory musculoskeletal pain were eligible to participate. GPs screened all patients in the consultation for the presence of depressive symptoms using two questions. All patients were sent a postal questionnaire within 1 week of consultation containing the Hospital Anxiety and Depression Scale and the written version of the depression screening questions. The total number of patients included in the study was 428. In total, 35.5% of consulters had comorbid depressive symptoms, with 13.5% experiencing moderate or severe symptoms. Just over half of participants (n = 218/242; 51.4%) screened positive on self-administered screening at home compared with only 78 (20.8%) on GP-administered screening in the consultation. There was little difference between GP-administered and self-administered screening in the probability of depressive symptoms among those who screened positive with regard to exhibiting signs of having depressive symptoms. Older patients consulting their GP with musculoskeletal pain frequently have comorbid mental ill health. Ultrashort depression screening questions administered during the consultation miss a large number of those with depressive symptoms, including six out of eight patients with severe symptoms. An improvement in the performance of screening questions in this patient group or narrowing the definition of 'high risk' from all patients aged > or =50 years presenting with musculoskeletal pain could help to improve detection.

Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome?

We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ-R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ-R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.

A case–control study of elderly patients with acute respiratory illness: Effect of influenza vaccination on admission to hospital in winter 2003–2004

Every winter, hospitals face a large increase in emergency respiratory admissions in elderly people. A case–control study was undertaken to assess the effect of routine influenza vaccine in preventing such admissions among a cohort of UK elderly presenting with acute respiratory illness during winter 2003–2004. 157 hospitalised cases and 639 controls (matched for age, sex and week of consultation) were interviewed. In a winter typical of levels of circulating influenza in recent years, influenza vaccine did not show a protective effect on emergency respiratory admissions overall (adjusted OR 1.2 (95%CI 0.8, 1.9). Policy makers should not rely solely on influenza vaccine routinely having a large effect on winter pressures, and should focus on additional preventive strategies.

Knowing a medical doctor is associated with reduced mortality among sick children consulting a paediatric ward in Guinea-Bissau, West Africa

To examine equity in access to public health services in Guinea-Bissau. The study was conducted in 2000-2001 at the emergency clinic of the only paediatric ward in Bissau. Mothers of all children from the study area were interviewed about previous care seeking and relations with anybody working in the health sector. All management actions in the emergency clinic were registered. In-hospital and subsequent community mortality was ascertained through community surveillance. The measured outcome was mortality risk within 30 days of first consultation. We followed 1572 children with a first consultation. Of these, 8.2% died within 30 days. Acquaintance with a physician reduced 30-day mortality risk by 48% (95% CI: 18-66). The effect was strongest among post-neonatal children (54%; 95% CI: 18-74). Mortality within 30 days of consultation was also independently predicted by consultation after 7 PM, nurse team on duty, day of week and young mother. In a multivariate model, socioeconomic status and school education were not associated with 30-day mortality when acquaintance with a medical doctor was taken into account. Favouritism may be a significant factor for quality of care and child mortality in developing countries. Interventions to improve hospital and health worker performance should be given high priority.