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This study examined factors of implementation in clinical practice across the world of the Pediatric Autism Communication Therapy, an evidence-based parent-mediated therapy. Data were gathered via a survey administered to professionals trained in Pediatric Autism Communication Therapy and parents with whom they worked. The study was a mixed-method design informed by the Consolidated Framework for Implementation Research. Over 70% of the practitioners recorded the intent to implement therapy after Pediatric Autism Communication Therapy training. Implementation was more likely if the practitioner saw mostly autistic children within their work (odds ratios ≈ 5), was easier with new referrals, and with peer support from colleagues and managers, allowing scheduling flexibility. The main barriers for practitioners were time (sessions > 1 h), suitable video equipment, low parental self-reflection abilities and family stress. Parents rated the feasibility of learning and using Pediatric Autism Communication Therapy in daily life highly (median = 5.4; interquartile range = 4.5, 6.8; range = 1–7) and delivered home-based practice a median of 4 days per week (daily practice recommended). The facilitators of implementation for parents included positive regard for the features of the Pediatric Autism Communication Therapy method (video reflection, parental empowerment, and play-based practice). The barriers for parents were mostly related to time availability. These results outline the importance of family and system-context factors necessary for successful parent-mediated therapy implementation. Factors influencing the implementation of parent-mediated intervention are insufficiently studied. This study examines for the first-time factors of implementation into clinical practice across the world of Pediatric Autism Communication Therapy, an internationally disseminated, evidence-based, parent-mediated therapy. From both the parents' and the professionals' perspectives, parents attitudes (e.g. self-reflection abilities and videotaping management) and life-circumstances (e.g. stressed families condition and time) were central factors. In this type of therapy, the target is a child's development; still, this improvement is dependent on the parent's behavior when interacting with their child. What's more, Pediatric Autism Communication Therapy method (video reflection, empowerment of parent, play-based) was enabler according to most of the parents. And more, most professionals report factors linked to the Implementation Process that is planning, execution, reflection and assessment in implementation of a new therapy. Indeed, the professionals underlined barriers related to the population seen in practice, flexibility of schedule, support from colleagues and manager. All these factors could be improved and addressed with a formal implementation plan including factors related to the parents of each country. [ABSTRACT FROM AUTHOR]

Primary care providers are often the first to identify concerns for autism through routine screening in the first 2 years of life. However, most children do not receive a diagnosis until years later resulting in delays accessing appropriate intervention. Delays in diagnosis disproportionately impact those who are otherwise disadvantaged by society based on race or socioeconomic status. Embedding mental health clinicians into primary care clinics offers a promising opportunity to address barriers to accessing diagnostic and intervention services once primary care providers identify concerns. The goal of this study was to assess the Autism in Primary Care program through which embedded mental health professionals in an urban primary care setting, primarily serving Black and Latinx families with Medicaid, were trained to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through Autism in Primary Care program. Wait times to access evaluations in primary care were found to be significantly shorter than through standard avenues of care (e.g. tertiary care clinics). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Embedding autism evaluations into primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being. Primary care providers often screen for autism during well child visits in the first few years of life and refer children for diagnostic evaluations when needed. However, most children do not receive a diagnosis until years later which delays access to services. Racism, socioeconomic status, and other systemic inequalities that limit access to health care further delay diagnostic evaluations. Mental health clinicians who work in primary care clinics can help address barriers to accessing diagnostic evaluation services once they are recommended by their primary care provider. However, mental health clinicians who work in primary care typically do not have training in diagnosing autism. The goal of this study was to evaluate a program training mental health professionals working in an urban primary care setting, primarily serving Black and Latinx families insured by Medicaid, to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through the Autism in Primary Care (APC) program. The wait time to access an evaluation through APC was significantly shorter than through standard avenues of care (e.g. referring to a separate autism clinic). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Conducting autism evaluations in primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being. [ABSTRACT FROM AUTHOR]

ECHO (Extensions for Community Healthcare Outcomes) Autism is a telementoring learning model to increase community capacity for autism-related health care. Seventy-seven pediatric providers (mostly primary care, seeing exclusively Medicaid patient populations) enrolled in 1 year of ECHO Autism Washington. Analysis of self-report surveys showed a significant increase in autism diagnoses made by ECHO providers after 1 year, F (1, 65) = 7.52, P =.008. Providers who attended more sessions reported making more diagnoses, F (2, 613.26), P =.045. Of note, autism diagnoses were not externally validated. The total number of reported barriers reduced, F (2, 61) = 13.5), P <.001, and confidence ratings increased F (2, 60) = 24.21, P <.001. The average number of diagnostic referrals from ECHO providers to the state's largest autism specialty clinic significantly reduced, t (43) = 4.23, P <.001, with significantly fewer diagnostic referrals made during and after ECHO training compared with a comparison group of 28 non-ECHO providers, t (58.77) = −3.36, P <.001. Overall, 1 year of ECHO Autism Washington participation led to significant changes in autism diagnostic practices. [ABSTRACT FROM AUTHOR]

Universal depression screening in adolescent primary care often encompasses questions about suicide risk. We conducted a retrospective chart review of well-child visits where adolescents (ages 13-17.9) had endorsed self-injurious thoughts and behaviors or suicidal ideation. The goal was to investigate primary care providers' follow-up actions, including documentation, further assessment, and referrals. Over 3-quarters of the progress notes showed evidence of further assessment, and two-thirds documented same-day actions, including mental health referrals, emergency department referrals, safety plans, medication changes, primary-care follow-up, and talking to parents. Actions varied by depression severity. Cases without interventions often had justifications. Owing to the variety of possible meanings and severity underlying positive screens, providers implemented an array of interventions, using clinical judgment to tailor actions to patients' individual needs and preferences. From these observations, we propose that standardized guidelines for suicide risk screening and follow-up should involve a clinical assessment and individualized treatment planning. [ABSTRACT FROM AUTHOR]

There is growing international evidence of the benefits of early perinatal palliative care for babies and their families. Despite this, inconsistency remains in ways care is provided by services including fetal medicine, maternity and neonatal services, and children's hospices. The aim of this study was to answer the question " What are the benefits and barriers to family-centered perinatal advance care planning from the perspective of professionals involved in the care of neonates and infants with life-limiting conditions? " Three focus groups comprising hospice practitioners were held across the UK. A lack of awareness of the role of hospices was described as the biggest barrier to referral to hospice services. Practitioners unanimously described having a physical presence alongside teams, as being the biggest contributor to improved multiagency working, facilitated through joint working and education provision. Early referral to hospice services, in parallel with curative services led to better outcomes and experiences of families, according to participants. [ABSTRACT FROM AUTHOR]

The Physical Activity Guidelines for Americans (Guidelines) advises older adults to be as active as possible. Yet, despite the many benefits of physical activity, less than 15% of people ages 65 years and older meet the Guidelines. To address this, the U.S. Department of Health and Human Services developed a Midcourse Report focused on the strategies and settings that can help increase physical activity levels among older adults. Internists are well positioned to encourage older adults to be more physically active. Health care providers can leverage this position to talk about the importance of regular physical activity; assess physical activity levels; share information and resources about how to safely get started; and provide counseling, guidance, and/or referrals to additional providers or programs for further support. This article provides an overview of the recently released Physical Activity Guidelines for Americans Midcourse Report: Implementation Strategies for Older Adult and highlights the role of internists and other health care providers to encourage and support their patients to be more physically active. [ABSTRACT FROM AUTHOR]

Objectives: As the understanding of the pathophysiology of chronic rhinosinusitis has increased over the last few years, it has been discovered that biologic therapy targeting type 2 inflammatory molecules can be beneficial for those with difficult-to-treat chronic rhinosinusitis with nasal polyposis. Given the recency of biologics, there is somewhat limited evidence on when to prescribe these medications and who should receive them. A recent consensus paper published by a group of Canadian rhinologists gave recommendations regarding prescribing biologics to patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). This study aimed to outline current practices and prescribing patterns of biologics for chronic rhinosinusitis in Canada and contrast this to existing guidelines. Materials/Methods: An online survey was distributed to members of the Canadian Rhinology Group of the Canadian Society of Otolaryngology—Head and Neck Surgery. The survey contained 44 questions, with 17 questions covering various topics related to criteria for initializing biologic therapy, investigations ordered prior to initialization of a biologic, and follow-up schedules. The responses were subsequently compared to clinical guidelines. Results: Twenty-one physicians responded to the survey. One response was discarded for this analysis as the respondent did not prescribe biologics. The biologic agent of choice for the majority of physicians (85%) was Dupilumab (Dupixent). The most used patient-reported outcome measure used was the SNOT-22 (80%), and most physicians (90%) confirm that their patients have undergone adequate sinus surgery with a computed tomography (CT) scan prior to considering biologic therapy. Investigations ordered prior to therapy and follow-up schedules varied. Only 10% of respondents consistently refer their patients to a multidisciplinary clinic prior to prescribing biologics despite recommendations in guidelines, but 70% involve an allergist and/or a respirologist in the care of these patients. Conclusions: Most respondents follow the recommendations made by the Canadian and international guidelines [European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA)]. The lack of multidisciplinary clinics across the country could be contributing to the low number of physicians using this resource for their patients despite recommendations. As our knowledge about biologics and CRSwNP improves, and with updated guidelines recently published, this survey should be expanded and repeated in the future to revaluate biologic prescribing practices in Canada. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: In the context of enrolling patients from primary care practices into a weight loss research study, this study describes the percentage of patients primary care clinicians (PCCs) considered appropriate for referral and study participation rates among those referred. Methods: An electronic health record review identified 5322 patients aged 18 to 75 years with BMI ≥ 30 kg/m2 as eligible for review by community, attending, and resident PCCs for referral to a weight loss study. Referrals and patient interest in participating in the study are reported overall and by PCC type. Results: The mean (SD) age was 53.1 (13.9) years, mean BMI 36.5 (6.2) kg/m2, 41.5% were male, and 30.9% were African American. PCCs reviewed 3882 patients and referred 2762 (71.1%) to the study. Of 1120 not referred, 260 (23.2%) were not known well enough by PCCs to assess for referral. The most common reasons for not referring included too much comorbidity (171, 15.3%), psychological reasons (170, 15.2%), and non-English speaking (125, 11.2%). Among 1897 patients invited to participate, 676 (35.6%) expressed interest and 360 (19.0%) were enrolled. Conclusions: PCCs referred 71.1% of their eligible patients. Among those referred, interest in participation was modest and enrollment was low. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04302727 [ABSTRACT FROM AUTHOR]

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and aggressive neoplastic process of precursor plasmacytoid dendritic cells. The diagnostic evaluation of this heterogenous entity is challenging, requiring a comprehensive approach of incorporating clinical, morphologic, immunohistochemical, and molecular/cytogenetic evaluations. Optimal management of BPDCN remains controversial, and clinical outcomes continues to be poor. Pediatric cases of BPDCN are rare and to our knowledge, this is the second case of BPDCN described in a Hispanic child, first one was described outside the US in Peru. Here, we report a case of a juvenile patient of Hispanic origin presenting with cutaneous and bone marrow involvement and initially misdiagnosed as a cutaneous infection that resulted in subsequent delaying of necessary chemotherapy for 2 months. Biopsy of the lesion showed diffuse infiltration of immature cells involving the dermis with classical sparring of epidermis. A huge panel of immunohistochemical stains were performed to reach the diagnosis of BPDCN. Staging bone marrow biopsy also revealed involvement by BPDCN. Treatment was not only delayed in this patient but also due to the rarity of BPDCN in pediatric population, the subsequent therapeutic decisions were challenging for the primary oncology team as it was based solely on published literature on adult population. Our case report will not only add one more case in the pediatric age group, but also will also emphasize that although BPDCN has a grave prognosis in the elderly, timely diagnosis with prompt treatment is the key to complete remission in pediatric BPDCN population. [ABSTRACT FROM AUTHOR]

Background: Breast cancer survivors (BCS) may experience cardiotoxicities from chemotherapy and oral endocrine therapy. Although a few studies have documented that palpitations are prevalent and associated with poorer outcomes, there is limited to no information on BCS' reporting of palpitations to healthcare providers. Objectives: To compare BCS who did and did not report their palpitations to a healthcare provider and describe how those who did report palpitations recalled their provider responding. Design: This was a cross-sectional, national, electronic, pilot survey of BCS enrolled in the Love Army of Women registry. Methods: Participants (n = 52 with palpitations) completed standardized and investigator-designed questionnaires. Data were analyzed using frequency and descriptive statistics, chi-square tests, and Mann–Whitney tests. Responses to one open-ended question were analyzed using frequency counts and standard content analysis. Results: Compared to BCS who reported palpitations to a provider (n = 34), BCS who did not report their palpitations (n = 18) were significantly more anxious (p = 0.002) and more likely to feel palpitations as an irregular heartbeat (70.6% versus 38.9%, p = 0.027). Among the 34 BCS who reported palpitations to a provider, 32 completed the open-ended question. Of these 32 BCS, a majority (n = 27, 84%) indicated their provider recommended cardiac testing and/or referral to a cardiologist. Most (n = 24) reported completing testing. Test results included diagnosis of a new arrhythmia or other cardiac abnormality (n = 11, 46%), receipt of a new prescription (n = 5, 21%), or normal results (n = 5, 21%). Five (16%) of the 32 BCS did not receive recommendations for testing or referral and felt their provider normalized or dismissed their symptoms. Conclusion: Palpitations are a salient topic for further research and clinical practice recommendations to address cardiac health in BCS. Plain language summary: What do breast cancer survivors tell health care providers abut heart symptoms and how do providers respond? Women who survive breast cancer can develop heart problems as a result of treatment. A common report of these women is feeling like the heart is beating faster, pounding, or beating irregularly. There is little research on what happens when breast cancer survivors have palpitations. Do they report them to a healthcare professional? If so, how does the healthcare professional respond? There were 52 survivors with palpitations who filled out an electronic survey; 34 reported their palpitations to a provider and 18 did not. Those who did not report palpitations were more anxious and more likely to feel their palpitations as an irregular heartbeat. Most of the women who reported palpitations to a provider received a recommendation for tests or referral to a heart specialist. Most completed the testing which resulted in finding a heart rhythm disturbance or other heart abnormality, getting a new prescription, or reassurance that things were normal. There were five women who did not get any recommendations for testing or referral. These women felt like their healthcare provider dismissed their symptoms as unimportant. [ABSTRACT FROM AUTHOR]

Evidence-based practice (EBP) is the cornerstone of contemporary healthcare, promoting the integration of scientific evidence, clinical expertise, and patient values to inform clinical decision-making and enhance patient outcomes. While patient engagement is recognized as a critical component of EBP, the extent to which it is incorporated in various EBP frameworks is unclear. This study is a secondary analysis of a scoping review which evaluated EBP frameworks used in healthcare settings. In the current study, our objective was to assess the level of patient engagement within those frameworks. To achieve this, we employed a patient engagement framework which characterizes engagement as a continuum, spanning consultation to involvement to shared leadership/partnership, across 3 healthcare domains: direct care, organizational design and governance, and policymaking. Our analysis revealed a gap in integrating patient values and preferences within EBP frameworks. Only 3 of the assessed frameworks showed a high degree of engagement across all domains. Future research should focus on developing strategies for implementing and evaluating meaningful engagement in EBP. [ABSTRACT FROM AUTHOR]

This study explores missed pediatric speech and language pathology (SLP) appointments to identify barriers for patients with speech disorders. Data from 839 referrals at Boston Medical Center, including demographics, appointment details, COVID-19 lockdown, and number of items on patient problem lists, were analyzed using chi-square tests and logistic regression. The findings revealed that lockdown status, appointment timing, appointment type (in-person vs telemedicine), referral department (ear, nose, and throat [ENT] vs non-ENT), sex, race, primary language, birthplace, and primary care provider presence had no significant impact on attendance. However, the number of patient-listed problems, prior cancelations, and missed appointments were significant predictors of patients who did not keep appointments. In conclusion, this research emphasizes the patient's problem list and past appointment behavior as critical factors in predicting missed SLP appointments for pediatric speech disorder patients. These insights can guide targeted interventions to improve attendance and enhance SLP engagement. [ABSTRACT FROM AUTHOR]

The Maryland's Premature Infant Developmental Enrichment (PRIDE) program is a unique collaborative endeavor between the University of Maryland School of Medicine and the Part C program for Baltimore City residents (Baltimore Infants and Toddlers Program; BITP). To evaluate the impact of PRIDE, the current study compared premature infants from low-income families who participated in BITP with (BWP) and without PRIDE (BWOP). A total of 956 premature infants (nBWP = 271; nBWOP = 685) were included in the study. Results showed that infants in BWP were referred at a younger age and stayed in BITP longer. A smaller percentage of parents in BWP withdrew from BITP and a larger percentage of BWP infants were eligible for special education preschool services under Part B of the Individuals with Disabilities Education Act (IDEA) at age 3. These findings provide support for the relative benefits of PRIDE to the traditional system of early intervention referral, evaluation, and service coordination. [ABSTRACT FROM AUTHOR]

Background: Providing efficient and targeted services for patients with mental health problems requires efficient collaboration and coordination within healthcare providers, but measuring collaboration using traditional methods is challenging. Aims: To explore the patient-sharing networks of professionals taking care of different groups of patients with mental or substance use disorders. Method: We used data that covered adult patients' visits to the primary care service providers of seven municipalities in Finland during year 2021. Data included 8,217 patients (147,430 visits) with mental or substance use disorders who were treated by 1,566 health care professionals. We calculated descriptive network metrics to examine the connectivity of professionals in three different patient groups (patients with substance use disorders, psychotic disorders, and depressive disorders) and compared these characteristics to a network based on all patients. We also analyzed whether patient sharing was associated with the health care professionals' attributes (occupational group, municipality) using Exponential Random Graph Models (ERGM). Results: Diagnosis-specific networks were denser and more connected compared to the all-patients network. Nurses were the most central occupation in all the diagnosis-specific networks and especially in the substance use disorder patients network. When examining all patients, two professionals were more likely to share patients when they belonged to the same occupational group. However, in the network with depressive disorder patients we found the opposite: professionals were more likely to share patients if they were of different occupational groups. Conclusions: Patient-sharing networks within patients with a specific mental or substance use disorders are denser and more connected than networks based on all patients with mental or substance use disorders. In the substance use disorder patients network particularly, nurses were the most central occupation. Multi-professional connections were more likely in depressive disorder networks than in the all-patients network. [ABSTRACT FROM AUTHOR]

Objective : Challenges providing cleft/craniofacial care in rural communities are often reported, leading to disparities in resources available to clinicians. The purpose of this study was to identify the impact of rurality on caseloads and practice patterns of speech-language pathologists (SLPs) regarding speech and velopharyngeal function for children with cleft lip and/or palate (CL/P). Design : A national, survey of US-based SLPs (N = 359 respondents) investigated resources, comfort level, caseloads, and practice patterns for children with CL/P. Sub-county classifications that delineated levels of rurality were utilized. Descriptive statistics and chi-square analyses were conducted to determine the impact of population density on assessment and referral decisions. Results : Nearly 83% of SLPs reported providing care for a child with CL/P and 41.4% of these SLPs reported five or more children with CL/P on caseload throughout their career. There were no significant differences in rurality of practice setting and the likelihood of treating a child with CL/P. Significant differences were present between rural, town, suburban, and metropolitan-based SLPs regarding available resources (p = 0.035). SLPs in rural settings reported feeling uncomfortable treating children with CL/P compared to those in metropolitan settings (p = 0.02). Distance to the cleft/craniofacial team and comfort levels impacted referral decisions. Conclusions : Most SLPs report having children with CL/P on caseload regardless of practice location. Rurality impacted assessment and referral decisions, especially surrounding access to resources and comfort levels engaging in team care. Findings have implications for developing support systems and reducing barriers for rural SLPs working with children born with CL/P. [ABSTRACT FROM AUTHOR]

Background: End-of-life care for patients with advanced cancer can impose a significant financial burden. However, data on the economic impact of end-of-life care in low- and middle-income countries are limited. Objective: This study aims to compare the costs associated with palliative care units (PCUs) and non-PCU settings for cancer patients in Iran. Design: We designed a retrospective study at the largest hospital in the country. Methods: We conducted a comprehensive evaluation of hospitalization costs and care service delivery for 150 patients in the final 5 days of life, who were admitted to the largest hospital complex in Iran. All costs were adjusted based on the 2018 USD exchange rate. Results: Among the 150 patients included in the study, 56 (37%) were admitted to the PCU. The average total treatment cost during the final 5 days of life was three times higher in general wards compared to PCUs. In non-PCU settings, the total cost of care during this period amounted to $2873, while in PCU settings, it was $909.63. Conclusion: The establishment of PCUs within tertiary hospitals and the provision of palliative consultation services to patients with advanced cancer can yield significant benefits, even when resources are limited. Plain language summary: An economic study about the cost of last five days of cancer patients in two different hospital ward, to show the importance of establishing palliative care in cancer hospitals in point of view of health economic An economic study about the cost of last five days of cancer patients in two different hospital ward, to show the importance of establishing palliative care in cancer hospitals in Iran, a low- and middle-income country in point of view of health economic. Why was the study done? There was only one hospital with palliative care setting in the country. Unfortunately in 2020 because of COVID-19 pandemic and the policy of hospital to use beds for COVID patients the PCU ward was closed and we tried to show the role of PCU and the importance of opening the ward again. What did the researchers do? The research team studied the cost of services that patients received during their last days of their life in PCU and non-PCU. What did the researchers find? Among the 150 patients included in the study, 56 (37%) were admitted to the PCU. The average total treatment cost during the final five days of life was three times higher in general wards compared to PCUs. In non-PCU settings, the total cost of care during this period amounted to $2873, while in PCU settings, it was $909.63. What do the findings mean? This study showed that having PCU in hospitals could save money and reduce the futile services. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: Community palliative care support teams specialize in providing at-home care under referral criteria distinct from hospital teams, focusing on functional status, limited benefit from continued hospital specialty care, and increased clinical complexity. This study aimed to assess the quality of referrals and the transition of care to a specialized community palliative care team, emphasizing adherence to established referral criteria. Methods: An observational, longitudinal, retrospective cohort study evaluated clinical health records of patients who received palliative care from a community team in 2023. We evaluated prior multidisciplinary follow-up, basic social support, medication changes made during the team's first consultation, and recurrences to hospital emergency care. The data was collected from the patients' clinical files. Results: The patient cohort had a mean age of 80.7 years (±11.92), ranging from 31 to 103 years. Males comprised 56.3% of the participants, with a median follow-up time of 32 days. Primary diagnoses included cancer (50%), end-stage organ failure (26%), and neurodegenerative disease (24%). Among the deceased, 85.6% died at home. Patients showed marked changes in psychological support and social rights, as we observed an improvement from 6.8% to 100% (P =.0011) and from 47.1% to 100% (P =.01) in these supports, respectively. We also observed significant changes in pharmacotherapeutic plans, regardless of the referring team. The study observed significant difficulty in recognizing referral criteria for specialized palliative care and defining clinical complexity. Referrals were often delayed, particularly for those previously under hospital care (P =.001). Increased prescription of pro re nata medications significantly correlated with home deaths (P =.021). Conclusions: Most complex patients can be effectively monitored and die at home, reserving hospital deaths for exceptional cases requiring interventions not possible at home or due to significant caregiver burden. There was no difference in the biopsychosocial approach of patients previously followed by other teams, including hospital palliative care teams, which suggests very different approaches. [ABSTRACT FROM AUTHOR]

Orthostatic intolerance (and its subtype postural orthostatic tachycardia syndrome [POTS]) is an increasingly common complaint among adolescents associated with significant decrease in quality of life and frequent visits to primary care offices. As orthostatic intolerance becomes increasingly discussed online and through social media, we have observed that family angst and anxiety only heighten, often leading to requests for specialist referral to manage the symptoms. This often leads to delay in diagnosis, which further exacerbates the situation. In truth, however, a pragmatic approach applied by the primary care provider, including a ready explanation for the experienced symptoms, not only provides the bedrock for patient improvement, but also eases the anxiety of having a seemingly nebulous diagnosis. As physicians caring for these patients, we have seen success with treatment and seek to share this blueprint. Key points that will be covered include how to make an accurate diagnosis (using the "dizziness rule"), how to counsel about treatment, and clinic pitfalls to avoid. The description of care that follows is not based on systematic review and instead is exactly what is used in our office and what we hope will be successful in yours as well. [ABSTRACT FROM AUTHOR]

In an online, survey-based experiment, musculoskeletal surgeon members of the science of variation group (n = 243) and a group of consult-liaison psychiatrists (n = 18) read 5 hypothetical scenarios of patients recovering from musculoskeletal trauma, each containing 5 randomized patient variables, and indicated their recommendation for psychiatry consultation or not. Factors associated with recommendation for psychiatry consultation included younger age, history of a psychiatric disorder, and pre-injury use of antipsychotic medications, and scenarios involving psychosis, suicidality, hallucinations in the setting of substance withdrawal, and questionable capacity for informed consent, but not with sadness alone. Musculoskeletal surgeons can collaborate with psychiatrists to develop comprehensive care for inpatients with musculoskeletal trauma starting with relatively pressing mental health needs and perhaps expanding into treatment of sadness or worry that can manifest as greater symptom intensity and a delayed recovery trajectory. [ABSTRACT FROM AUTHOR]

Background: Knowledge of access to palliative care services, such as palliative care consultation teams, is crucial to identify areas of improvement for policy and practice. Research on general populations spanning all disease groups and multiple healthcare contexts is needed. Objective: The objective was to investigate the sociodemographic, disease- and care-related, and care structure-related factors associated with palliative care consultations for adult patients in the last week of life. Design: Cross-sectional, general population-level study based on linked Swedish national public authority registers and a national palliative care quality register. Methods: The study population included all adult patients deceased in Sweden between 2013 and 2019 and registered in the Swedish Register of Palliative Care, with an anticipated death, and not enrolled in specialised palliative care. Multivariable logistic regression analyses to investigate association with palliative care consultations. Results: In total, 8.2% of the 265,129 participants had received a palliative care consultation in the last week of life. The main multivariable analysis (Model 1) showed that those dying from neoplasms were more likely to receive a palliative care consultation (odds ratio (OR) 8.55, 95% CI 8.15–8.98) than those dying from circulatory diseases. Palliative care consultation was more likely with an increasing number of symptoms (OR 1.35, CI 1.32–1.37). Patients of old age and patients deceased in hospitals were less likely to receive a palliative care consultation. Moreover, factors such as educational attainment, healthcare region, living in a single-person household, and year of death were also associated with a palliative care consultation in the last week of life. Conclusion: Our findings show inequities in access to palliative care consultations in the last week of life. Considering changes to policy and clinical practice is motivated. [ABSTRACT FROM AUTHOR]

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the current status and workload of telenursing by home healthcare nurses in the post-COVID-19 era, where telenursing has become indispensable, and identify factors that influence the intention to use telenursing. This study employed a cross-sectional descriptive approach based on an online survey. A total of 137 active home care nurses were surveyed for over 6 weeks starting in December 2022. Among the participants, 33.8% (N = 44) responded that they were currently using telenursing services. Most telenursing was conducted for consultation and education, using various technologies. The intention to use telenursing was significantly higher among individuals with higher educational levels and telenursing experience. The greater the social influence, which indicates the extent to which people around them believe that telenursing should be used, and more positive the attitudes toward telenursing, the higher the intention to use it. A clear definition of telenursing is required to improve people's understanding of telenursing before its official implementation in Korea. Telenursing may be used to provide health care education and consultation while maintaining the continuity of care not only for patients receiving home health care but also for community-dwelling patients. To recognize and evaluate current telenursing practices, telenursing content should be recorded accurately. Finally, attitudes toward telenursing and social influence must be considered when developing strategies to improve nurses' intentions to use and activate telenursing in the near future. [ABSTRACT FROM AUTHOR]

Early intervention is known to improve long-term outcomes for individuals with autism spectrum disorder (ASD). Access barriers to care limit timely engagement with supportive services. This report characterized the community needs and supportive services for children and families with suspected or diagnosed ASD. Families and providers participating in outreach clinics identified available services and their attitudes about support for ASD diagnosis. Chart reviews provided referral history, insurance, and current services. Children were nearly 6 years old, 95% of families relied on public health insurance, whereas 50% reported traveling 11 miles or greater for supportive services. Most providers (83%) were medically trained in primary care and placed 1-5 referrals per month to a tertiary referral hospital. Providers reported travel difficulty as the primary reason for referring patients for evaluation. Multiple barriers for supportive services were identified, highlighting the importance to increase the capacity and availability of local ASD supportive services. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic brain injury (TBI) can disrupt the hypothalamo-pituitary axis, causing neuroendocrine dysfunction. As a third of children can develop post-traumatic hypothalamo-pituitary axis dysfunction (HPAD), a longitudinal follow-up is required in children with TBI. Method: The study comprised a pre-quality improvement (QI) phase (baseline phase) and a QI phase (post-intervention phase). Retrospective data were collected on children with TBI at our hospital during the pre-QI phase of the study to estimate the baseline data on HPAD prevalence and pediatric endocrine referral rate. Guidance protocol for standardizing the pediatric endocrine referral, evaluation, and follow-up of children with TBI was implemented. Prospective data were collected to estimate outcome measures (prevalence of HPAD, rate of initial endocrine consultation and outpatient follow-up) and process measures (protocol adherence rate). Result: Twenty-seven children, aged ≤19 years, were admitted with TBI in the pre-QI phase. The median age was 9 years. Motor vehicle accidents predominated. Thirty percent had limited endocrine evaluation, and 4% had transient cranial diabetes insipidus (DI). The QI phase included 8 children. Demographic data were similar to those in the pre-QI phase. Both outcome and process measures increased to 75% from the pre-QI phase following the protocol implementation. Conclusion: A lower prevalence rate of HPAD in the current cohort may be owing to underevaluation and a smaller sample size. The QI initiative incorporating a guidance protocol-based endocrinological approach to children with TBI improved the pediatric endocrinology referral and follow-up rates. [ABSTRACT FROM AUTHOR]

The Canadian Association of Radiologists (CAR) Cardiovascular Expert Panel is made up of physicians from the disciplines of radiology, cardiology, and emergency medicine, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 30 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 48 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 125 recommendation statements across the 30 scenarios (27 unique scenarios as 2 scenarios point to the CAR Thoracic Diagnostic Imaging Referral Guideline and the acute pericarditis subscenario is included under 2 main scenarios). This guideline presents the methods of development and the referral recommendations for acute chest pain syndromes, chronic chest pain, cardiovascular screening and risk stratification, pericardial syndromes, intracardiac/pericardial mass, suspected valvular disease cardiomyopathy, aorta, venous thrombosis, and peripheral vascular disease. [ABSTRACT FROM AUTHOR]

One-third of U.S. adults have prediabetes, but only 11% are aware of their condition. Many do not receive education or treatment. The purpose of this study is to understand family medicine providers' and patients' attitudes, knowledge, and behaviors regarding prediabetes and its management, to guide future management interventions. Cross-sectional surveys of providers (n = 54, 57% response rate) and patients with prediabetes (n = 148, 16.5% response rate) were administered at a large urban academic family medicine practice. Nearly all providers agree prediabetes screening is important, but over half were unaware of the national Diabetes Prevention Program (DPP) and most do not prescribe metformin to eligible patients. Over half of patients reported being told they have prediabetes but <5% had been referred to DPP and over half were unaware of medication options. In open-ended responses, providers suggested nutrition counseling resources and an improved DPP referral process to improve prediabetes care. Patients requested clear diagnosis, education on treatment options, and nutritional counseling. This study indicates that notable gaps continue to exist in provider and patient understanding and management of prediabetes, suggesting that interventions to improve prediabetes care should include more effective counseling on diagnosis and treatment and expanding access to nutrition and educational resources. [ABSTRACT FROM AUTHOR]

Prescribing lifestyle behavior change is a recommended strategy for both primary and secondary prevention of disease. Programs that support and encourage lifestyle behavior change are available to patients but are underutilized. The purpose of this study was to understand primary care providers (PCPs) experiences and barriers they experience with referring patients to lifestyle behavior change programs at one academic health care system. In-depth semi-structured interviews were conducted with 7 academic PCPs between November 2020 and January 2021. Qualitative analysis identified major themes. Four themes emerged: (1) guideline awareness and adherence, (2) barriers to lifestyle behavior change recommendations, (3) provider role with respect to lifestyle behavior change recommendations, and (4) suggestions to improve utilization of behavior change support. Specific strategies for improvement include revising referral process, educating providers about programs already offered, integrating a team-based approach, and systemizing healthy lifestyle behaviors interventions. The lessons identified through this study highlight the need for systematic prioritization of lifestyle behavior change to decrease certain barriers that providers face when attempting to integrate lifestyle change consistently into their practice. [ABSTRACT FROM AUTHOR]

Background: Researchers and clinicians often use the six-item abbreviated Posttraumatic Stress Disorder Checklist–Civilian (PCL-6) for screening; however, the PCL-6 has not been validated for parents of children with cancer. A valid and reliable short screener like the PCL-6 would allow bedside and/or advanced practice nurses to quickly screen parents for traumatic stress and expedite referrals for support services. Method: This study used data collected during a multisite trial examining an intervention for children with cancer and their parents. This dataset included parental self-report measures of traumatic stress (PCL-6; Impact of Events Scale-Revised [IES-R]), mood disturbance (Profile of Mood States-Short Form [POMS-SF]), and wellbeing (Index of Wellbeing [IWB]). The sample included 136 parents of children (3-8 years old) undergoing cancer treatment at four hospitals. Analysis: For construct validity, we calculated Spearman's correlation coefficient using baseline scores of the PCL-6 with baseline scores for the IES-R, POMS-SF, and IWB. For internal consistency, we calculated Cronbach's alpha using the scores of each of the six items of the PCL-6 for all parent/caregiver participants at baseline. Results: Results indicate good convergent construct validity, reasonable divergent construct validity, and good internal consistency. [ABSTRACT FROM AUTHOR]

Introduction: Biceps tendinosis, a milder form on the spectrum of biceps tendinopathy, is unusual at the distal insertion site. Patients with distal biceps tendinosis may experience pain and dysfunction which could inhibit their activities of daily living. Diagnosis of distal biceps tendinosis may be facilitated with ultrasonography (US), whose accuracy is increasingly recognised, while providing many benefits over other modalities, like magnetic resonance imaging (MRI). Case report: We report two cases of distal biceps tendinosis diagnosed by US with clinical details, imaging findings and patient management. Two patients present with elbow pain after nontraumatic activities. US revealed a thickened distal biceps tendon with mild heterogeneous hypoechogenicity without fibre disruption or retraction in both cases and evidence of hyperemia on Doppler with surrounding bursal fluid in case 2. Discussion: Tendinosis has variable aetiologies, but US commonly cannot differentiate among these; therefore, patient's clinical history is the major component in determining the underlying cause. Chronic progression of tendon pathology leads to partial and full thickness tears. Tendinosis has a characteristic US appearance. US has many benefits and clinicians may use this modality to assess possible pathological structures with ease, convenience and efficiency compared with using MRI. Conclusion: Distal biceps tendinosis may present with clinical symptoms of pain and decreased activities of daily living, and may progress to more severe forms of tendinopathy. Early diagnosis is beneficial for the treatment outcomes of this condition. US can visualise distal biceps tendinosis with reliability, providing an alternative diagnostic technique with many benefits compared with MRI. [ABSTRACT FROM AUTHOR]

Purpose: Breast arterial calcifications (BAC) on mammography have been correlated with increased cardiovascular risk. The Canadian Society of Breast Imaging released a position statement on BAC reporting in January 2023. This study evaluates the awareness of the clinical significance of BAC and reporting preferences of referring physicians in Canada. Methods: A 15-question survey was distributed to Canadian physicians who may review mammography results via regional and subspecialty associations and on social media following local institutional ethical approval. Responses were collected over 10 weeks from February to April 2023. Results: Seventy-two complete responses were obtained. We are unable to determine the response rate, given the means of distribution. Only 17% (12/72) of responding physicians were previously aware of the association between BAC and increased cardiovascular risk, and 51% (37/72) preferred the inclusion of BAC in the mammography report. Fifty-six percent (40/72) indicated that BAC reporting would prompt further investigation, and 63% (45/72) would inform patients that their mammogram showed evidence of BAC. Sixty-nine percent (50/72) would find grading of BAC beneficial and 71% (51/72) agreed that there is a need for national guidelines. Conclusion: Less than a quarter of responding Canadian referring physicians were previously aware of the association between BAC and cardiovascular risk, although half of respondents indicated a preference for BAC reporting on mammography. Most participating physicians would inform their patients of the presence of BAC and consider further cardiovascular risk management. There was consensus that a national BAC grading system and clinical management guidelines would be beneficial. [ABSTRACT FROM AUTHOR]

Consultation following evidence-based practice (EBP) training enhances the uptake of EBPs. Yet, little is known about what occurs during consultation, and it is often difficult for providers to engage in consultation. This study examined provider engagement in consultation and the content and strategies used during consultation following training in Trauma-focused Cognitive Behavioral Therapy (TF-CBT) as part of a community-based learning collaborative (CBLC). Minute-to-minute live coding of consultation calls revealed most content was clinically-oriented and the most common strategies used by consultants were didactic in nature. Providers with more years of professional experience and those with greater TF-CBT knowledge attended significantly more consultation calls. Providers with a greater average weekly caseload and providers who were supervisors presented significantly more cases on calls. Providers with greater TF-CBT knowledge spoke significantly more minutes on calls. Consistent with previous work, findings highlight difficulties with provider engagement in consultation and that providers with more baseline expertise are most likely to be engaged. Findings suggest tailoring EBP training efforts to better engage providers at greatest risk for low engagement. [ABSTRACT FROM AUTHOR]

Background: Esophagogastroduodenoscopy (EGD) is the gold standard method for diagnosing upper gastrointestinal (GI) pathology. Swedish guidelines recommend patients over 50 years with new-onset dyspeptic symptoms undergo direct gastroscopy to rule out malignancy. However, the incidence of dysplasia or cancer in patients aged 61–70 years remains unclear. Objectives: To investigate the referral factors and endoscopic findings in patients aged 61–70 years and compare the result with age groups 51–60 and 41–50 years from our previous studies to establish whether there is an age cutoff for upper GI cancer risk. Design: A retrospective observational study was conducted to evaluate EGD referrals and outcomes in patients aged 61–70 years. Methods: We analyzed EGD referrals for patients aged 61–70 years within Region Örebro County from January 2019–April 2020 to January 2022–2023. Clinical data, including symptoms, medications, and laboratory results, were collected from medical records. Statistical analysis, including odds ratios (OR) and positive predictive values (PPV), was conducted to evaluate pathological outcomes based on referral factors. Results: A total of 1003 referrals were analyzed. Statistically significant differences in pathological findings were observed between the 41–50 years reference group and the older groups (51–60 years: OR 2.08, p < 0.001; 61–70 years: OR 3.05, p < 0.001). However, no statistically significant difference in cancer incidence was found between the age groups. Conclusion: The most common pathological findings were benign, including hiatal hernia, gastroesophageal reflux disease/esophagitis, or gastritis. The incidence of cancer was low in all three groups. These results suggest that the "test-and-treat" strategy, currently recommended for patients under 50 years, may be appropriate for patients aged 51–70 years as well. Trial registration: NCT04585516. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: Comprehensive eye exams are recommended at least every 2 years for people with diabetes for early identification and treatment of diabetic eye disease, but screening rates remain suboptimal. Our objective was to qualitatively assess barriers and facilitators to completing recommended eye exam screening for patients with diabetes among providers and practice staff. Methods: As part of a larger initiative, we conducted discussion groups with healthcare providers and practice staff to evaluate factors related to referral and screening for diabetic eye disease at 2 sites, a safety-net healthcare system and a specialty clinic. Discussions were audio-recorded and transcribed. Combined inductive, deductive thematic content analysis was conducted, applying the Practical Robust Implementation and Sustainability Model to organize themes and subthemes. Results: Two discussion groups with 28 participants were conducted in August 2023. Themes included existing processes for referrals, scheduling, and tracking; patient-level determinants including transportation and financial barriers and other competing demands to receiving recommended eye screening; clinic or system-related factors, and considerations for process improvement for eye exam referrals and appointments. Conclusions: These findings can be applied to determine the most effective strategies to improve the rates of recommended eye exam referral and screening rates in people with diabetes. [ABSTRACT FROM AUTHOR]

Background: Obesity has a significant impact on healthcare resources with limited accessible support available through the NHS. This service evaluation determines 24-month efficacy of referral to an open-group behavioral program by BMI category and socioeconomic status. Methods: This retrospective, longitudinal study examined weight outcomes of adults living in England referred by healthcare professionals to Slimming World during 2016 who recorded at least 1 weight change. Primary outcome was % weight change at 3, 6, 12, and 24 months. Socioeconomic status was measured using the Index of Multiple Deprivation (IMD). Data from a post-referral questionnaire investigated self-reported changes in dietary and activity behaviors. Results: Twenty-seven thousand five hundred sixty (15.6% male) records were analyzed. Mean (SD) age and BMI on joining were 48.6 (14.80) years and 37.1 (6.31) kg/m2; 91.7% had a BMI > 30 kg/m2. Mean (SD) % weight change was −5.6 (3.79), −7.1 (5.71), −7.5 (6.88), and −7.3 (6.88) at 3, 6, 12, and 24-months, respectively. At 24- months, differences in weight loss between BMI category were significant, ranging from 0.29% (35-<40 vs 40+) to 1.33% (25-<30 vs 40+). For IMD quintile only comparisons against Q1 and Q2 were significant, ranging between 0.36% (Q2 vs Q3) to 0.94% (Q1 vs Q5). Five thousand eight hundred sixty-two (21.2%) completed the post-referral questionnaire. There were no BMI category effects on dietary behaviors but changes in physical activity behaviors were lower within the higher categories albeit effect sizes were small (all ges < 0.001). IMD quintile influenced changes for sugary drinks, watching TV and avoiding moderate activity although effect sizes were small (all ges < 0.01). Conclusion: Following 12-week referral to a commercial weight management organization, a mean weight loss of over 7% was reported at 24-months. Adults with higher BMIs and a greater level of deprivation can benefit from the practical support offered as part of the referral, supporting weight loss and weight loss maintenance albeit with some inequality. [ABSTRACT FROM AUTHOR]

Introduction: People experiencing health-related social needs (HRSNs), such as transportation insecurity, are less likely to undergo preventive health screenings. They are more likely to have worse health outcomes overall, including a higher rate of late-stage cancer diagnoses. If primary care clinicians are aware of HRSNs, they can tailor preventive care, including cancer screening approaches. Accordingly, recent guidelines recommend that clinicians "adjust" care based on HRSNs. This study assessed the level of clinician awareness of patient-reported HRSNs and congruence between clinician perception and patient-reported HRSNs. Methods: We surveyed patients aged 50 to 85 years and their clinicians in 3 primary care clinics that routinely screen patients for HRSNs. Patients and clinicians reported the presence/absence of 6 HRSNs, including food, transportation, housing and financial insecurity for medications/healthcare, financial insecurity for utilities, and social isolation. Kappa statistics assessed the concordance of reported HRSNs between patients and clinicians. Results: Across 237 paired patient-clinician surveys, mean patient age was 65 years, and 62% and 13% of patients were female and Latinx/Hispanic, respectively. Concordance between clinician- and patient-reported HRSNs varied by HRSN, with the lowest agreement for food insecurity (kappa =.08; 95% CI: 0.00, 0.17; P =.01) and highest agreement for transportation insecurity (kappa =.39; 95% CI: 0.18, 0.59; P <.001). The other HRSNs assessed were housing insecurity (kappa =.30; 95% CI: 0.05, 0.55; P <.001), social isolation (kappa =.24; 95% CI: 0.03, 0.45; P <.001), financial insecurity for utilities (kappa =.21; 95% CI: −0.02, 0.45; P <.001), and financial insecurity for healthcare/medications (kappa =.12; 95% CI: −0.02, 0.27; P <.001). In particular, discrepancies were noted in food insecurity prevalence: patient-reported food insecurity was 29% whereas clinician-reported food insecurity was only 3%. Discussion: Clinician awareness of patients' social needs was only modest to fair, and varied by specific HRSN. In order to adjust care for HRSNs, clinics need processes for increased sharing of patient-reported HRSNs screening information with the entire clinical team. Future research should explore options for sharing HRSN data across teams and evaluate whether better HRSN data-sharing impacts outcomes. [ABSTRACT FROM AUTHOR]

Appropriate status epilepticus (SE) management is key to minimize admission to the pediatric intensive care unit (PICU). We retrospectively describe 115 children admitted to the PICU of the tertiary-care referral hospital of Padova for seizures, SE, and SE-related complications (59% from second-level hospitals, 41% from the referral hospital) and compare SE management among hospitals. Compared with the referral center, in second-level hospitals, anesthetics were more often administered as first/second drug (P <.001), and intubation was more frequent (P <.001). Intubation was significantly associated with SE onset at home (P =.045) and benzodiazepine-associated respiratory depression (P =.044). There was no association between intubation and SE duration, etiology, PICU length of stay, and morbidity at discharge. In conclusion, adherence to treatment protocols on SE management after the first-line drug differs between referral center and second-level hospitals. Lack of association with SE characteristics and patient's outcome suggests PICU admission could be due to inappropriate invasive management. [ABSTRACT FROM AUTHOR]

Background: Chronic pain is highly prevalent in US military Veterans, and pain interdisciplinary teams (IDTs) are the gold standard in pain care. There is no standard or guidance for how best to develop and implement pain interdisciplinary teams within complex health care systems. Objectives: The purpose of this quality improvement project was to evaluate the effectiveness of the standard 9-step Lean 6 Sigma (LSS) methodology in redesigning a pre-existing VA outpatient pain clinic solely offering interventional pain services into an efficient, sustainable pain IDT program. Methods: The initial evaluation process at a VA Medical Center that primarily serves rural Veterans was redesigned with the a priori goal of developing an efficient, sustainable IDT program that decreased driving days (ie, in-person appointments) required for a comprehensive initial pain evaluation, decreased number of consults required for initial pain evaluations, increased the number of consults to Whole Health services, and increased compliance with policies and standards. Feedback from administrators, clinicians, and Veterans was used to identify inefficiencies then iteratively design, test, and finalize a redesigned service called the PREVAIL Interdisciplinary Team Track (PREVAIL IDT Track). Baseline data was collected for 1 year followed by sustainment data for 14 months. Results were analyzed using descriptive statistics. Results: PREVAIL IDT Track decreased the number of in-person appointments from 5 to 2, decreased consults required for evaluations from 5 to 1, increased the number of unique consults to Whole Health education classes, and made the VA fully compliant with policies and standards. To date, 486 Veterans have participated in the redesigned program, including 167 graduates and 212 current enrollees in this sustained clinical program. Conclusion: The success of PREVAIL IDT Track suggests that LSS may be a promising method for redesigning sustainable pain IDTs in VA that improve efficiency. [ABSTRACT FROM AUTHOR]

Background: Homeless-experienced adults smoke at rates 5 times that of the general adult population, and often have limited access to cessation treatments while homeless. Permanent Supportive Housing (PSH) can be a catalyst for cessation treatment utilization, yet little is known about use of these treatments following PSH entry, or how to tailor and implement cessation care that meets homeless-experienced adults' vulnerabilities. Methods: Using Department of Veterans Affairs (VA) administrative data, we assessed smoking status (ie, current, former, non/never) among a cohort of homeless-experienced Veterans (HEVs) housed in Los Angeles-based PSH. We compared cessation treatment use rates (ie, nicotine replacement therapies, cessation medications, psychosocial counseling) pre- and post-housing using Chi-square tests. Predisposing (ie, demographics), enabling (eg, primary care, benefits), and need characteristics (ie, health, mental health, substance use diagnoses) were examined as correlates of cessation treatment utilization pre- and post-housing in univariable and multivariable logistic regression models. Results: Across HEVs (N = 2933), 48.6% were identified as currently-smoking, 17.7% as formerly-smoking, and 14.0% as non/never smoking. Among currently- and formerly-smoking HEVs (n = 1944), rates of cessation treatment use post-housing were significantly lower, compared to pre-housing, across all treatment types. Health, mental health, and substance use was more prevalent among currently- and formerly-smoking HEVs compared to non/never-smoking HEVs, and most diagnoses were positively associated with utilization univariably. However, in multivariable models, cessation clinic referrals and primary care engagement were the only significant (P <.001) predictors of pre-housing and post-housing cessation treatment utilization. Conclusion: Among HEVs, we found high smoking rates and low cessation treatment utilization pre- and post-PSH entry. Efforts to educate providers about this population's desire to quit smoking, support primary care engagement, and increase cessation clinic referrals may bolster their utilization. For homeless-experienced adults, optimizing cessation treatment accessibility by embedding cessation services within PSH and homeless service settings may reduce utilization impediments. [ABSTRACT FROM AUTHOR]

Hypercalcemia can result from either hyperparathyroidism or non-parathyroid conditions. When hypercalcemia is accompanied by undetectable parathyroid hormone (PTH) levels, hyperparathyroidism is rarely considered the diagnosis. Herein, we report the case of a 65-year-old Caucasian woman referred to our hospital for further evaluation of hypercalcemia. Her symptoms included fatigue and brain fog, with undetectable PTH levels. A comprehensive workup, including a series of laboratory and imaging tests, excluded common non-parathyroid causes such as malignancy and familial hypocalciuric hypercalcemia. Ultrasound identified a likely enlarged parathyroid gland, which was further confirmed by a sestamibi scan. After 2 weeks of cinacalcet treatment, the patient's calcium levels decreased, indicating the parathyroid gland as the likely source of hypercalcemia. Parathyroidectomy was subsequently performed, revealing a 1927 mg adenoma. Postoperatively, the patient's calcium levels normalized, PTH levels became detectable within the normal range, and her symptoms resolved, with a marked improvement in energy. This case demonstrates that primary hyperparathyroidism can present with hypercalcemia and undetectable PTH. A genetic mutation in the PTH gene within the adenoma may explain the undetectable PTH levels preoperatively. Plain Language Summary: This case report discusses a 65-year-old woman who was found to have high calcium levels in her blood, a condition known as hypercalcemia. Typically, hypercalcemia can result from either a condition where the parathyroid glands produce too much parathyroid hormone (PTH) or from other non-parathyroid-related issues like cancer. However, when hypercalcemia occurs with undetectable levels of PTH, it is unusual for hyperparathyroidism to be the cause. In this patient's case, she experienced symptoms like fatigue and brain fog, but her initial tests showed undetectable PTH levels. Further tests ruled out other common causes of high calcium, such as cancer or a genetic condition called familial hypocalciuric hypercalcemia. An ultrasound and a special scan called a sestamibi scan revealed an enlarged parathyroid gland, suggesting the presence of a parathyroid adenoma, a non-cancerous tumor. To confirm this, the doctors gave the patient a medication called cinacalcet, which is known to lower calcium levels if the parathyroid glands are involved. After two weeks of treatment, her calcium levels dropped, indicating that the parathyroid gland was indeed the source of the problem. The patient underwent surgery to remove the adenoma, which weighed nearly two grams. Following the surgery, her calcium levels returned to normal, and her PTH levels became detectable again within the normal range. Her symptoms, including fatigue, improved significantly, and she reported feeling more energetic. This case is unusual because it demonstrates that primary hyperparathyroidism can still be the cause of hypercalcemia even when PTH levels are initially undetectable. The doctors suspect that a genetic mutation in the adenoma might explain why PTH levels were undetectable before surgery. This case emphasizes the importance of thorough clinical evaluation, even when initial test results are not typical. [ABSTRACT FROM AUTHOR]

Background and Aims: This study aims to investigate the clinicopathological profile of cervical lymphadenopathy in a tertiary referral centre. The findings will contribute to a deeper understanding of the disease spectrum, aid in accurate diagnosis, and help in improving patient treatment and outcomes. Methodology: This is a prospective study conducted in the Department of ENT, Head and Neck Surgery, Apollo Hospital, Chennai, between June 2022 and May 2023. The clinicopathological profile of all patients was analysed. The final histological diagnosis and the preoperative Fine Needle Aspiration Cytology (FNAC) were correlated. The primary tumour was identified in cases with metastatic secondary tumours in the neck. Results: Among the 80 patients in our study, 67% had a benign aetiology (most common was tuberculosis), and 33% had a malignant aetiology (most common was Hodgkin's Lymphoma). Gender distribution was equal, with those between the ages of 35 and 60 more frequently affected. The nasopharynx (30%) was the most likely location of the occult primary, followed by the thyroid (20%) and larynx (20%). In detecting TB, FNAC had a sensitivity of 75.5% and a specificity of 98%; in detecting lymphomas, it was 64% and 100%; in detecting metastatic secondaries, it was 80% and 100%; and in detecting reactive lymphadenitis, it was 79% and 86%. Conclusion: Cervical lymphadenopathy is a common entity requiring careful evaluation and treatment. PET scans prove invaluable in detecting occult primary tumours. FNAC is an initial, cost-effective diagnostic tool. However, biopsy is indicated in specific conditions to obtain accurate diagnosis to enable prompt treatment. [ABSTRACT FROM AUTHOR]

Background: Distal renal tubular acidosis (dRTA) is a condition characterized by the impaired ability to secrete hydrogen ions from the distal tubule. In pediatric patients, common clinical features of dRTA include excessive urine production (polyuria), frequent nighttime urination (nocturia), poor growth and weight gain (failure to thrive), difficulty with bowel movements (constipation), abnormal breathing, and the presence of kidney stones (nephrolithiasis). While urinary tract infections (UTIs) are frequently associated with dRTA, renal failure is uncommon and seldom reported in children. Case Presentation: A 10-year-old girl was referred for the evaluation due to a progressive loss of gross motor milestones over a period of 3 years. She also experienced an acute episode of paralysis and was found to have bilateral medullary nephrocalcinosis (right staghorn calculus) accompanied by moderate renal failure and a UTI. Her development in other areas was appropriate for her age. Importantly, there was a history suggestive of excessive urine production (polyuria), increased thirst (polydipsia), and frequent nighttime urination (nocturia). Physical examination revealed proximal myopathy, characterized by a waddling gait and a positive Gower's sign, as well as diminished reflexes and muscle tone in the lower limbs. Laboratory tests indicated the presence of sepsis (total leukocyte count – 26,660, CRP-174.29) and elevated renal parameters (serum creatinine – 4.27) along with active urinary abnormalities. Urine culture and sensitivity testing showed significant growth of Escherichia coli (>100,000 CFU). A computed tomography scan of the kidneys, ureters, and bladder revealed a staghorn calculus on the right side, as well as bilateral medullary nephrocalcinosis and swollen kidneys. The patient was diagnosed with dRTA based on several factors, including hypokalemic hyperchloremic metabolic acidosis with a normal anion gap, high urine pH, borderline hypercalciuria, presence of medullary nephrocalcinosis, and after ruling out other potential differential diagnoses. Following treatment for the UTI and sepsis, as well as standard treatment for dRTA, the child exhibited symptomatic improvement. Her creatinine levels returned to 0.8 mg/dL, and the septic markers declined to normal levels. To further investigate the cause of the initial decline in renal function in addition to the UTI, a renal biopsy was performed. Conclusion: This case report emphasizes the significance of including medullary nephrocalcinosis and renal tubular acidosis in the list of potential diagnoses for patients presenting with progressive gross motor developmental regression, acute flaccid paralysis, and proximal myopathy. Timely identification of these conditions can help avoid unnecessary and expensive investigations, while also facilitating prompt clinical recovery in affected children. Early diagnosis plays a crucial role in guiding appropriate management strategies and improving patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Investigational drug service (IDS) oversees and manages use of investigational products. There is limited data on utility of pharmacy services in clinical trial conduct and outcomes, specifically on the value of a decentralized IDS pharmacist. Methods: This is a quasi-experimental study conducted in an oncology clinical trial infusion unit. A retrospective chart review was done to reflect current practice from January through June 2022. A decentralized IDS pharmacist was piloted in December 2022. Data collected included number and types of consults, personnel requesting the consult, and intervention performed. A satisfaction questionnaire was conducted after the pilot program. Results: A total of 16.3% (173 of 1062 patient visits) of pharmacy consults were completed in the centralized IDS pharmacy model, while 44.5% (81 of 182 patient visits) of pharmacy consults were completed during the decentralized IDS pharmacist pilot, p <.001. Decentralized IDS pharmacist completed 77% (62/81) of the consults during the pilot period. Most common types of consults were toxicity management (20%), electronic medical record issues (17%), and tubing and drug administration issues (16%). More than 80% of respondents to the satisfaction questionnaire responded that implementation of a decentralized IDS pharmacist is acceptable, appropriate, and feasible. Conclusion: This pilot study demonstrated that a decentralized IDS pharmacist in an oncology clinical trial infusion unit improved accessibility to an IDS pharmacist, increased pharmacy consults relevant to patient care and optimized centralized pharmacists medication distribution workflow. Further studies are needed to evaluate patient benefits from implementing decentralized IDS pharmacist in direct patient care activities. [ABSTRACT FROM AUTHOR]

Peripheral nerve sheath tumors encompass a spectrum of well-defined clinicopathologic entities, ranging from benign tumors, such as neurofibromas, to high grade malignant neoplasms termed malignant peripheral nerve sheath tumors. Morphologic variability of these tumors is wide, and they engender some of the most controversial, difficult differential diagnoses. Localized neurofibromas often involve a major nerve and result typically in fusiform expansion of the nerve trunk (intraneural subtype). We report a case of circumscribed solitary neurofibromas in a 14-year-old boy with NF1 who presented to our department with a left neck swelling. The neurofibromas lesion involved the anterior branch of the great auricular nerve. The sensory symptoms initially reported by the patient (paresthesia and hyperesthesia) in the lower preauricular region. Surgical treatment represents the therapeutic method of choice in the approach to neurofibromas, considering functional disorders and possible aesthetic deformities. The case described presented difficulties in surgical excision, based on risk of functional and aesthetic results. [ABSTRACT FROM AUTHOR]

Background: Palliative care is an essential component of children's health services but is accessed by fewer children than could potentially benefit. Aim: Appraise the evidence to identify factors influencing referral and access to children's palliative care, and interventions to reduce barriers and improve referrals. Design: Scoping review following the six stages of the Arksey and O'Malley framework. Data were charted using an adapted version of the socioecological framework. Data sources: CINAHL, MEDLINE, PsycINFO, EMBASE, Cochrane Library were searched for primary studies of any design and literature/systematic reviews. Studies reporting barriers/facilitators and interventions in relation to referral of children with a life-limiting condition to palliative care, in any setting, were included. Results: One hundred ninety five articles (primary qualitative and quantitative studies, reviews) were retained (153 reporting barriers/facilitators; 40 interventions; 2 both). Multiple factors were identified as barriers/facilitators: Individual level: underlying diagnosis, prognostic uncertainty, parental attitudes, staff understanding/beliefs; Interpersonal level: family support, patient-provider relationships, interdisciplinary communication; Organisational level: referral protocols, workforce, leadership; Community level: cultural norms, community resources, geography; Society level: policies and legislation, national education, economic environment, medication availability. Most of these factors were bi-directional in terms of influence. Interventions (n = 42) were mainly at the organisational level for example, educational programmes, screening tools/guidelines, workplace champions and new/enhanced services; one-third of these were evaluated. Conclusion: Barriers/facilitators to paediatric palliative care referral are well described. Interventions are less well described and often unevaluated. Multi-modal approaches incorporating stakeholders from all levels of the socioecological framework are required to improve paediatric palliative care referral and access. [ABSTRACT FROM AUTHOR]

Introduction: In low- and middle-income countries (LMICs), including South Africa, there is a paucity of psychosocial support services. Therefore, services are often provided in schools by non-government organisations like Community Keepers (CK). The COVID-19 pandemic and resultant restrictions meant that children and young people's (CYP) lives changed, negatively affecting their mental health. Further, organisations like CK had to change their working processes. Method: This project compared routinely collected data from CK from 2019 (pre-pandemic) to 2020 (pandemic) to describe the changes that occurred in referral patterns to, and service provision by, CK. Results: Both pre-pandemic and during the pandemic, most referrals of CYP were for emotional/psychological support and behavioural difficulties. In 2020, referrals for general guidance increased, whilst referrals for peer group issues and sexuality decreased. Further, CK completed more brief check-ins, provided wellbeing workshops to increased numbers of teachers, parents and CYP, and had more consultation sessions with other service providers during the pandemic. Discussion: Routinely collected data from this community-based service in a LMIC context shows differences in the way that support was provided, and to whom, during the COVID-19 pandemic. Clinical implications, including the importance of increasing access to psychosocial support via technology, are included. Plain language summary: The COVID-19 pandemic disproportionately impacted children, young people and families who are most vulnerable, including those in low- and middle-income countries (LMICs). Within LMICs, the lack of trained psychological professionals and investment in mental healthcare interventions means access to help is limited. School-based provision, which may increase access to mental health support was curtailed during school closures when face-to face service provision was prohibited. It is well-documented that the COVID-19 pandemic impacted CYP's mental and emotional well-being. However, it is less well understood how the need and service provision of third sector non-government organisations changed during this time. Thus, we partnered with a non-government organisation, Community Keepers (CK) who are based in Western Cape, South Africa to understand how referral patterns changed from 2019 (pre-pandemic) to 2020 (peri-pandemic) and explore the specific adaptations that CK made to service provision. CK aims to provide free mental health care services to CYP, their parents (legal guardians / primary caregivers; henceforth referred to as parents) and teachers, on-site at schools (www.communitykeepers.org). Results suggest that both pre-pandemic and during the pandemic, most referrals of CYP were for emotional/psychological support and behavioural difficulties. In 2020, referrals for general guidance and chronic/serious illness increased, whilst referrals for peer group issues and sexuality decreased. Further, CK completed wellbeing workshops to increased numbers of teachers, parents and CYP, and had more consultation sessions with other service providers during the pandemic. In addition, COVID-19 restrictions necessitated a reduction in face-to-face sessions and a move towards more systemic support as well as telephonic and/or online support to individuals. This paper demonstrates that should another global crisis like the Covid-19 pandemic occur, necessitating school closures and/or restrictions to in-person interaction, it will be important for organisations working in schools, particularly with CYP who are particularly vulnerable, to pivot their provision to enable continued support. Further, specific recommendations for CK were given regarding data collection, that can be used to support growth and understanding service provision patterns across similar settings. [ABSTRACT FROM AUTHOR]

Objectives: This retrospective cohort study aims to understand the effectiveness of the Singular Therapeutic Project (STP) implemented in a Child Psychosocial Care Center in preventing recurrence of self-harm and suicide attempt (SA), by comparing the group of patients who adhered to the STP with the group that did not adhere completely. Method: Data were collected from the medical records of adolescents with self-harm or SA during the period from 2015 to 2019. The primary outcomes analyzed were recurrence of SA, self-harm, and hospitalization; and the secondary outcomes analyzed were demographics, diagnosis, number of appointments, and negative life events. Results: A total of 228 adolescents were included. After multivariate analysis, social service consultations decreased risk in 94.6% (HR.054, 95% CI:.004–.681) of the cases, but risk was increased by 23 times if there was an episode of self-harm among family members and/or friends (HR 23.641, 95% CI: 1.394–400.8). Additionally, in terms of SA, adherence to family interventions reduced the risk by 66.2% (HR.338, 95% CI:.125–.913). Victims of prejudice, racism, homophobia, transphobia presented a 3.7-fold increased risk (HR 3.766, 95% CI: 1.058–13.401). Conclusion: The STP interventions were effective in reducing the recurrence of self-harm and SAs in adolescents. [ABSTRACT FROM AUTHOR]

Black and non-White Latinx children have historically been diagnosed with autism at a later age and with more significant impairments than White peers. This study aimed to gather insights from members of the autism service provider workforce on current barriers and facilitators to achieving equity in early childhood autism evaluation, referrals, and treatment. We employed a qualitative descriptive design using semi-structured virtual focus groups with autism experts in North Carolina (N = 26). Our final sample included pediatric clinicians across disciplines, researchers, family/caregiver advocates, and policymakers/government representatives. We identified four overarching themes representing challenges to equitable autism service provision: (1) workforce composition and recruitment concerns, (2) workforce capacity and accessibility concerns, (3) workforce compensation obstacles, and (4) COVID-19 pandemic adaptations' impact. Our findings demonstrate the need for improved workforce diversity, autism-specific education, adequate compensation, and interventions to address burnout. To remediate existing barriers to equity, diversity in recruitment across training levels, cultural awareness, autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow its interdisciplinary professionals to better meet the needs of children and families from historically marginalized communities and achieve equitable early childhood service provision. Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) w orkforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services. [ABSTRACT FROM AUTHOR]

The available literature is scarce on the initial symptoms of arterial hypertension in children. Our study aimed to analyze the initial clinical profile of patients referred to the hospital with suspected hypertension and those diagnosed with hypertension for the first time during a hospitalization for other reasons. This study was a retrospective analysis of medical records in 471 patients. More than half of the patients showed no symptoms. The most common symptom reported was a headache—28% (132) of patients. The diagnosis of elevated blood pressure or hypertension was more frequent in asymptomatic patients (P = 0.001). Headaches were seen more often in healthy patients than in patients with hypertension. Newly diagnosed hypertension is mainly diagnosed in asymptomatic children. Moreover, the symptoms previously described in the literature as the most common did not prove to be predictive of hypertension in our study. [ABSTRACT FROM AUTHOR]

We aimed to investigate clinical and laboratory characteristics of acute alcohol intoxication (AAI) in adolescents who presented to the pediatric emergency department (ED) at a tertiary referral center from 2006 to 2019. All consecutive adolescents with AAI (n = 335) and their sex- and age-matched control subjects (n = 335) with undetectable ethanol levels were included in this case-matched study. Mean serum ethanol level was 156.4 ± 58.4 (range: 50.8-341.2) mg/dL in the acute alcohol intoxication (AAI) group. Glasgow coma scores were lower in AAI group (14 [14-15] vs 15 [15-15], P <.001). Acidosis (16.3%), hyperlactatemia (60.9%), hypoglycemia (1.7%), hypernatremia (2.2%), hypokalemia (12.3%), hyperchloremia (20.4%), hypocalcemia (13.9%), hypermagnesemia (9.7%), and hyperalbuminemia (10.4%) were significantly more common in the AAI group than the control group. Blood pH, lactate, Na+, K+, Ca++, Mg++, albumin, blood urea nitrogen (BUN), and uric acid levels were correlated with serum ethanol levels. This study shows that AAI frequently leads to mild to moderate metabolic/biochemical derangements in adolescents. [ABSTRACT FROM AUTHOR]

Primary care providers (PCPs) can play an important role in the continuity of care for children who experience sexual abuse (SA). We performed a retrospective, chart-based study of children 3 to 17 years old with SA history. Primary care medical records were reviewed for 2 years after a subspecialty SA evaluation. Descriptive statistics and logistic regression were used to assess factors associated with documentation of SA history and mental health management by the PCP. Of 131 included patients, 43% had PCP documentation of their SA history, which was associated with care from resident providers (P <.01). There was greater mental health management and mental health referrals by PCPs for the group with documentation compared with the group without documentation (52% vs 23%, P <.001). Overall, child SA history was poorly documented in primary care settings. Identifying mechanisms to improve communication about a child's SA history with PCPs is important for the child's ongoing care. [ABSTRACT FROM AUTHOR]