Search

Objective: Oral cancer examinations seek to clinically identify early oral cancers and discover premalignancies prior to their progression to invasive cancer. Method and materials: A cross-sectional study was conducted between April and August 2017 to explore and quantify the diagnostic approach used by United States (US) general dental practitioners following discovery of an oral lesion suspicious for malignancy/premalignancy. US licensed general dental practitioners who were clinically active members of the US National Dental Practice-Based Research Network were eligible to participate. Data for analysis were obtained via two questionnaires. Results: The majority of participants were males, practiced full-time, had a suburban primary practice, were born during the 1950s, and graduated dental school in the 1980s or 2000s. After identifying an oral lesion suspicious for premalignancy/malignancy, the next action of most general dental practitioner respondents (65.4%) was to refer the patient for consultation/biopsy. Most general dental practitioners (87.2%) referred to an oral and maxillofacial surgeon; 22% of general dental practitioners reported personally biopsying suspicious lesions. There was a relatively weak association between completing an Advanced Education in General Dentistry or General Practice Residency and subsequently personally performing biopsies on patients with oral lesions suspicious for malignancy/premalignancy (OR 1.33, P = .06). Most written referrals took place electronically and often included information, including lesion location (87.0%), lesion sign/symptoms (85.3%), lesion history (83.9%), radiographs (59.3%), medical history (50.6%), dental history (48.8%), and photographs (42.4%). When a referral biopsy was performed, referring clinicians were most frequently informed of the findings via a written report (96.7%, when positive for malignancy/premalignancy, and 95.4% when negative). Conclusion: A snapshot is presented of current actions taken by US general dental practitioners following the discovery of oral abnormalities suspicious for premalignancy/malignancy. [ABSTRACT FROM AUTHOR]

Context: A healthy, 22-year-old, male NCAA Division I baseball shortstop was experiencing confusion, chest pain, and tightness during an off-season intersquad scrimmage. The patient did not have any significant medical history or mechanism of head injury. After initial evaluation from the athletic trainer, the patient's cognitive status began to quickly decline. The emergency action plan was put in place rapidly and referred the patient to the local emergency clinic. Case Presentation: Upon arrival at the emergency department, an electrocardiogram was performed to rule out myocardial infarction or stroke. The first electrocardiogram results returned negative for any cardiac pathology, but a stroke alert was called. The patient was then transported to a level II trauma center due to continual cognitive decline. The patient was diagnosed with transient ischemic attack (TIA) secondary to an undiagnosed patent foramen ovale (PFO) that would later be diagnosed with further evaluation 2 months after the initial TIA incident. After multiple diagnostic and laboratory tests, the PFO went undetected until a 2D echocardiogram was performed and evaluated by a cardiologist. Management and Outcomes: After the confirmation of the congenital defect, surgical intervention was performed to correct the PFO using catheterization. Despite multiple preparticipation examinations, electrocardiograms, and examination of past family history, the PFO went undetected until the patient experienced symptoms of TIA. The discovery of PFO in this 22-year-old athletic individual is unusual because traditional screening techniques (electrocardiogram and preparticipation examinations) failed to detect the congenital defect. Conclusions: Due to the emergent and timely actions of the athletic trainer, the patient has made a full recovery and is able to compete fully in athletic events. This case study amplifies the need for athletic trainers at all sporting events, updated and reviewed emergency action plans, rapid recognition of TIA in athletic individuals, and return-to-play protocol for an athletic individual after TIA. [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]

Background: Post-stroke depression is among the most common neuropsychiatric complications in stroke survivors. Post-stroke depression is commonly under-recognized and under-treated. This study aimed to assess the prevalence and associated factors of post-stroke depression among patients on follow-up at medical referral clinics of Bahir Dar City public specialized hospitals. Method: An institutional-based prospective cross-sectional study was conducted from September to December 2023 on 394 patients. Public Health Questionnaire-9 was used to diagnose depression. Data was checked for cleanness manually and then exported to SPSS version 25 software for analysis. A systematic randomized sampling method was used to identify study participants. Bivariate and multivariate logistic regression analysis was performed to identify independent predictors of post-stroke depression. A p-value less than 0.05 is considered as significant with a 95% confidence interval. Result: The overall prevalence of post-stroke depression was found to be 42.9%. Employment status (AOR = 0.282, 95% CI: 0.112–0.709 C, P-value = 0.007), depression before stroke (AOR = 3.237, 95% CI: 1.098–9.544, P-value = 0.033), ischemic heart disease (AOR = 4.090, 95% CI: 1.745–9.583, P-value = 0.001) and physical disability (AOR = 4.051 95% CI: 2.239–7.332, P-value = 0.000) were found to be statistically significant independent predictors of post-stroke depression (PSD). Conclusion: The prevalence of post-stroke depression was found to be high relative to other similar studies. Patients with known depression before stroke, ischemic heart disease, and significant physical disability were at a higher risk of developing PSD. Employed patients had less risk of developing PSD. Sufficient and comprehensive evaluation of stroke patients for depression is recommended. [ABSTRACT FROM AUTHOR]

Background: To address the rising demand for urgent care and decrease hospital use, health systems are implementing different strategies to support urgent care patients (i.e. patients who would have typically been treated in hospital) in the community, such as general practitioner (GP) advice lines. The aims of this study were to: identify the support and resources GPs need to manage urgent care patients in the community; assess the need for GP advice lines by primary care services in Australia; and identify the facilitators and barriers to adoption, and strategies to support the sustainability of GP advice lines. Methods: Qualitative study involving semi-structured interviews with GPs, hospital-based healthcare providers, consumers, and healthcare management, recruited via existing investigator networks and snowballing approach. The interviews were conducted between February and August 2023. Major themes were identified by an iterative and inductive thematic analysis. Results: We interviewed 16 participants (median age 50, IQR 38–59). Based on the aims of the study, three themes emerged: support and resources for GPs; motivation for GP advice lines; and factors influencing the uptake and sustainability of GP advice lines. Participants reported that better communication from hospital services with GPs is critical to ensure continuity of care between tertiary and primary settings. They also noted that GP advice lines can help increase capacity to manage urgent care patients in the community by providing timely decision-support to GPs. However, a reported barrier to the uptake and ongoing use of GP advice lines was the limited hours of the service. To sustain GP advice lines, participants highlighted a need to broaden the scope of the service beyond the pandemic, conduct rigorous evaluation on health outcomes, and further digitise the service so that a tiered level of support could be provided based on risk stratification. Conclusions: The benefits of GP advice lines are yet to be fully realised. With increasing technology sophistication, there remain opportunities to further digitise and optimise GP advice lines, whilst ensuring better integration within and across primary and tertiary care services. This is however dependent on continued financial and policy support from the government. [ABSTRACT FROM AUTHOR]

Background: Ductulography is a key imaging technique for assessing nipple discharge. Despite modern advancements such as mammography and MRI, the relevance of ductulography in diagnosing pathologic nipple discharge (PND) remains significant, particularly in low-resource settings. This review examines our single-center experience with ductulography in Indonesia, highlighting patient characteristics and procedural outcomes. Methods: This review is based on case-based experiences from a private tertiary hospital in Indonesia, a main referral center for ductulography. We describe 28 women who underwent ductulography between January 2019 and June 2024. This review is supplemented by the theories of ductulography and how we do it in our institution. Results: The median age of the patients was 46.5 years (IQR: 42–53.5 years). Among the 28 women, 2 experienced non-spontaneous discharge, 12 had colorless discharge, 12 had bloody discharge, and the remaining had yellowish to brownish discharge. Laterality was almost evenly distributed with 14 right-sided, 13 left-sided, and 1 bilateral discharge. The Galactogram Imaging Classification System (GICS) outcomes were 2 patients with GICS 0, 7 with GICS 1, 17 with GICS 2, and 2 with GICS 4a. Histopathologic analyses were performed on three patients, revealing fibrocystic changes in two and intraductal papilloma with fibrocystic changes in one. Conclusions: While ductulography may be considered an older technique, it remains a valuable diagnostic tool in the modern imaging era, especially in settings with limited access to advanced imaging modalities. Our single-center experience supports the continued use of ductulography, providing crucial preoperative mapping and aiding in the accurate diagnosis of PND. [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]

Aim: The aim of this revision was to update the Remote Area Nurse (RAN) Model of Consultation (MoC) and was prompted by publication of the National Rural and Remote Nursing Generalist Framework (2013–2018), shifts in RAN workforce patterns, community health patterns and technology use. Context: Rural and remote residents face higher rates of hospitalisations, deaths and poorer access to health care with a significant burden of avoidable fatal conditions among Aboriginal and Torres Strait Islander peoples. Health care is mostly provided by RANs and Aboriginal and Torres Strait Islander Health Practitioners (ATSIHPs), addressing diverse health needs, a mobile population and navigating cross‐cultural situations. Despite challenges such as clinician shortages, RANs manage a significant portion of non‐emergency consultations. The RAN MoC was developed to ensure comprehensive, systematic and person‐centred care and to mitigate risk to the client, the nurse and the health service. Approach: The 11 expert panel members, all authors, revised the RAN MoC through a series of Microsoft Teams meetings, one face‐to‐face meeting and an exchange of emails. The principles were reorganised under the four domains of the National Rural and Remote Nursing Generalist Framework and mapped against the National Safety and Quality Primary and Community Health Care Standards. Conclusion: The revised RAN MoC is designed to provide evidence based culturally informed care, standardise RAN consultation best practice and improve the health outcomes of their clients. With the increased turnover and number of nurses 'new' to remote, more innovative approaches to education and dissemination of the model is necessary. [ABSTRACT FROM AUTHOR]

Objectives Many choices are made in the context of one's social network, but age differences in consulting others during decision making remain underexplored. This preregistered study examined age differences in the composition of decision-related social networks and associated social preferences and motivations. Based on prior findings regarding age differences in information-seeking and socioemotional preferences, we predicted that with advanced age people would consult fewer and more emotionally close social partners, consult them less frequently, rate consultations as more helpful, and prioritize social goals during decision making. Methods An adult lifespan sample (N  = 485; M age   = 51.08; SD age = 19.63, rangeage   = 18–96 years) considered hypothetical choices and reported how many and what types of people they would consult and how often they would consult them. They also identified their most important decision consultants and evaluated interactions with those individuals. Results As predicted, age was associated with consulting fewer people less frequently and this was not explained by having a smaller range of potential consultants in one's network. Contrary to predictions, the proportion of close social partners in decision networks and the perceived helpfulness of consultants did not vary significantly by age. Moreover, older adults were less likely than younger adults to prioritize relationship quality over decision quality. Controlling for potential covariates did not diminish the observed age effects. Discussion These findings align with the prior literature on age-related decrements in pre-decisional information seeking but suggest that age-related preferences for close social partners and socioemotional goals do not extend to decision-related consultations. [ABSTRACT FROM AUTHOR]

Many patients who could benefit from palliative care (PC) do not access it because of the timing and tenor of the introduction provided by their specialist. A barrier to improving specialists' (from disciplines other than PC) engagement with PC services may be an inadequate understanding of how those specialists view PC. As part of a larger project to develop public messaging for advance care planning, PC, and hospice, we conducted a qualitative market research study aimed at identifying the "deep metaphors" held by specialists about PC to provide an empirical foundation for more effective outreach and messaging. To identify deep metaphors, we used the qualitative Zaltman Metaphor Elicitation Technique to uncover thought patterns from participants' images and interview responses, revealing deeper emotional meanings and unconscious mental orientations. We enrolled 20 provider-level clinicians from a variety of professional disciplines and specialties to participate in a one-hour semi-structured interview that required prework. The interviews were videorecorded and transcribed and were analyzed along with images brought by participants using a variation of the constant comparative method. The themes included: Having to tell patients the "right" information and path; Not allowing myself to make mistakes; Depending on algorithms so I can give my patients the best care; Putting the patient in charge can challenge clinical algorithms; Observing that PC seems to lack an objectively "right" decision; Consulting PC invites subjectivity best contained at the end of the algorithm. These themes can inform strategies for outreach and messaging to other serious illness specialist clinicians to lower reluctance to consult PC, increasing patient access. [ABSTRACT FROM AUTHOR]

The State-wide Outreach Perinatal Services – Mental Health (SwOPS) is a telehealth consultation liaison service aimed at bridging the gap in perinatal mental health service provision in rural and remote areas across New South Wales (NSW), Australia. The service enables health professionals working within the NSW health service to refer perinatal women with moderate-to-severe or complex mental health conditions for assessment and treatment advice by a perinatal psychiatrist and senior clinical nurse consultant. There is, however, limited research evaluating the impact of the service. The current study represents the first qualitative investigation into the experiences of health professionals accessing the SwOPS service. Qualitative interviews were conducted with 12 health professionals from rural, remote and metropolitan areas who had experience with the SwOPS service. Data was analysed using a thematic analysis approach, four themes and 14 sub-themes were identified: accessing the SwOPS service (limited resources in rural and remote areas, expert advice, and education and clinical supervision), unique and valuable service (easy access and reduction in wait-times, reduces admission and re-presentation, and service providers and capacity building), benefits to health professionals (education, peer networking and community of practice, comprehensive reports), and room for improvement (need for increased resources, cultural sensitivity, expand service, access to electronic medical record, and improve marketing). Results highlight the limited resources available to rural and remote perinatal mental health services providers. Further, findings highlight the need for services such as SwOPS to help bridge the gap in the provision of mental health services and rural and remote areas. Highlights: Access to mental health services during the perinatal period in rural and remote areas is limited. The State-wide Outreach Perinatal Services – Mental Health (SwOPS) service aims to bridge the gap in mental health services available in rural and remote areas. Mental health consultation-liaison services assist clinicians to better plan for and provide current and ongoing patient care. Study findings provide insight into health practitioners' perspectives of a telehealth delivered psychiatry consultation-liaison service. Findings will contribute to the implementation of similar programs nationally and internationally. [ABSTRACT FROM AUTHOR]

Objective: Telepsychiatry consultations grew rapidly with increased total consultations and reduced face-to-face consultations following the pandemic-triggered expansion of Medicare Benefits Schedule (MBS) telehealth items. It was unclear how much telehealth expansion independently impacted overall and face-to-face consultation trends after accounting for lockdown severity. Methods: We extracted monthly MBS Item Reports for psychiatric consultations (January 2012–December 2023). The monthly average Stringency Index (SI) for Australia represented lockdown severity from January 2020 to December 2022. A dichotomous variable denoted telehealth expansion (March 2020 onward). We constructed consecutive multiple linear regression models for combined consultations and face-to-face consultations to include seasonality, trend, SI, and telehealth expansion. We compared model performance using information criteria. Results: Median monthly total consultations increased from 148,413 (Interquartile range, IQR: 138,219–153,709) pre-expansion (January 2012–February 2020) to 173,016 (IQR: 158,292–182,463) post-expansion (March 2020–December 2023). Contrarily, median monthly face-to-face consultations decreased from 143,726 (IQR: 135,812–150,153) to 99,272 (IQR: 87,513–107,778). Seasonality and trend were present in both time series. The time series regression model with expansion but excluding SI best explained all consultations, while both telehealth expansion and SI were significant in the best-fit model for face-to-face consultations. Conclusion: MBS telehealth expansion was associated with total and face-to-face consultations independent of lockdown severity changes. Policy changes allowing wider access to new telehealth services have possibly led to increased uptake of psychiatric care and addressed previously unmet needs. What is known about the topic? A large rise in telepsychiatry consultations with increased total consultations and reduced face-to-face consultations followed the pandemic-triggered expansion of Medicare Benefits Schedule telehealth items. What does this paper add? We demonstrated that after adjusting for pre-existing trends, seasonality, and COVID-related restrictions, telehealth expansion was associated positively with all consultations and negatively with face-to-face consultations at clinically significant levels. What are the implications for practitioners? Policy changes widening telepsychiatry services have possibly led to increased uptake of psychiatric care by addressing previously unmet needs. Hybrid face-to-face/telehealth care may become the new norm. [ABSTRACT FROM AUTHOR]

Deciding whether to transfer a non-euploid embryo presents a challenge for both individuals and clinicians involved in assisted reproductive technologies (ART) with preimplantation genetic testing (PGT). The uncertainty surrounding clinical outcomes and long-term effects complicates this decision, and there is limited research on the factors that influence individuals' experiences during this decision-making process. An online survey was utilized to gather data on elements influencing the decision-making process. The survey included both closed and open questions and targeted individuals worldwide who had undergone PGT during their fertility journey. A total of 135 responses were received, with complete data from 111 respondents analyzed. Three primary factors emerged as significant influences on respondents' decision-making: the opportunity to discuss the implications of the transfer, the topics covered during consultations, and the country where the treatment was received. The study also identified three major themes related to the challenges faced by respondents: mismatched expectations, inadequate information provision, and an unsupportive decision-making process. These results highlight the critical need for appropriate support when deciding to transfer a non-euploid embryo. Respondents emphasized the importance of comprehensive discussions about the implications of PGT results. The study underscores the necessity for proactive clinic communication, patient-centred information, and increased support for patients considering non-euploid embryos. [ABSTRACT FROM AUTHOR]

Purpose: Improvements in outcomes for adolescent and young adult (AYA) oncology patients have lagged behind those of other age-specific cancer populations. Research has indicated that low availability of clinical trials, biological differences of this age-group, and several psychosocial factors including higher emotional distress impact outcomes. To improve care and survival rates for these patients, hospitals have implemented AYA oncology programs. The current study evaluated documentation of care in an AYA program housed in an academic medical center based on three areas emphasized in the National Comprehensive Cancer Network's Clinical Practice Guidelines in Oncology for AYAs: clinical trial enrollment, fertility, and psychosocial care. Methods: Retrospective chart reviews were conducted for 45 patients treated before the start of the AYA oncology program and 45 patients treated after program initiation. Patients aged 15–39 years with a diagnosis of a malignant tumor were included. Variables evaluated included documentation of clinical trial enrollment, fertility preservation and sexual health considerations, and behavioral health referrals. Results: Documentation of most clinical trial and fertility variables did not significantly improve from pre- to post-program, although a higher number of patients had these variables documented post-program. Behavioral health referrals increased significantly from 52.8% pre-program to 95.4% post-program. Conclusion: Access to behavioral health care improved the most following implementation of our AYA program, which is likely because of the integration of a dedicated psychologist for AYAs when the program began. The practice of guideline-based care for this population can be better assessed and improved with designated behavioral health providers and more systematic documentation processes. [ABSTRACT FROM AUTHOR]

objective: At our large, university-affiliated primary care clinic, we aimed to enhance the quality of well-child checkups (WCCs) to align with Bright Futures/ American Academy of Pediatrics recommendations. Our primary goal was to increase the rate of complete WCCs from 45.6% to 80% by April 2024. Our secondary aims were to ensure WCC improvement for all language groups and to increase referrals to 2 community partners. methods: A multidisciplinary team initiated a quality improvement project primarily focused on transitioning from paper-based to electronic questionnaires for patient screenings. Clinic processes were developed to assist families in completing questionnaires. The percentage of complete WCCs was the primary outcome measure. We defined complete WCCs as those that included note documentation of all required patient-reported elements. Our primary outcome measure was analyzed by using statistical process control charts to identify special cause variation. results: We reviewed 51809 WCCs from July 2022 to April 2024, and the rate of complete WCCs improved from 45.6% to 84.7%. We significantly improved the rates for all measured aspects of WCCs as follows: 7 different common pedi-atric questionnaires and 7 routine WCC assessments. Referrals to 2 community nutrition and literacy resources increased. Despite large improvements across all language groups, disparities remained for patients who spoke languages other than English. conclusions: Transitioning to electronic questionnaires and revised clinic procedures led to more comprehensive WCCs and connected more families with community resources. Although progress was made across all language groups, we note ongoing challenges in eliminating disparities. [ABSTRACT FROM AUTHOR]

Adverse childhood experiences (ACEs) are common and can impact health across the life course. Thus, it is essential for professionals in child- and family-serving roles, including pediatric and adult primary care clinicians, to understand the health implications of childhood adversity and trauma and respond appropriately. Screening for ACEs in health care settings has received attention as a potential approach to ACEs identification and response. Careful examination of the existing evidence on ACEs screening and consideration, from a clinical and ethical perspective, of the potential benefits, challenges, and harms is critical to ensuring evidence-informed practice. In this critical appraisal, we synthesize existing systematic and scoping reviews on ACEs screening, summarize recent studies on the ability of ACEs to predict health outcomes at the individual level, and provide a comprehensive overview of potential benefits, challenges, and harms of ACEs screening. We identify gaps in the existing evidence base and specify directions for future research. We also describe trauma-informed, relational care as an orientation and perspective that can help pediatric and primary care clinicians to sensitively assess for and respond to ACEs and other potentially traumatic experiences. Overall, we do not yet have sufficient evidence regarding the potential benefits, challenges, and harms of ACEs screening in health care and other settings. In the absence of this evidence, we cannot assume that screening will not cause harm and that potential benefits outweigh potential harms. [ABSTRACT FROM AUTHOR]

A 17-year-old female was diagnosed with inflammatory bowel disease and started on infliximab. A few weeks after starting infliximab, she developed a recurrence of daily fevers associated with an intermittent dry cough, which worsened over the course of a month. A chest radiograph, abdominal ultrasound, and computed tomography scan of the chest and abdomen revealed a heterogeneous spleen with multiple hyperechoic areas, tiny splenic micronodules, and diffuse micronodularity throughout the lungs. She was transferred to a tertiary care hospital because of hypotension, new oxygen requirements, and ongoing fever. Her bloodwork on presentation to tertiary care revealed pancytopenia and elevated inflammatory markers; she had splenomegaly on MRI. As her clinical picture evolved, she continued to have persistent fevers and anorexia despite ongoing management. Infectious diseases, rheumatology, and gastroenterology were consulted to guide the evaluation and management of this patient's complex clinical course. [ABSTRACT FROM AUTHOR]

Background: Infective endocarditis (IE) is a severe infection with considerable mortality. It is associated with geographical variation, complicating diagnosis and treatment of patients in a standardised manner. Aim: To evaluate the characteristics and management outcomes of patients with IE in Royal Perth Hospital (RPH). Methods: A single‐centre, retrospective cohort study. Data were collected from medical records of 131 patients with a diagnosis of IE admitted to RPH between 2016 and 2021. Results: Eighty‐four patients with definite IE were included for analysis. The median age of patients was 51.5 years and 77.4% were male. Compared to the general Australian population, there was disproportionately greater representation of Indigenous Australians (21.4%), those with a history of injecting drug use (IDU) (27.4%), rheumatic heart disease (14.3%) and previous IE (13.1%). The most commonly affected valve was the mitral valve in 46.4% of patients, and the most common pathogen was Staphylococcus aureus in 47.6% of patients. Twelve‐month mortality was 16.7%, with significantly increased mortality in those treated non‐surgically (25.6% vs 7.3%, P = 0.025). Factors associated with undergoing surgery included the presence of aortic valve disease, perivalvular extension of infection and infection with Enterococcus faecalis, whereas IDU, tricuspid valve disease and S. aureus infection were associated with non‐surgical management. Adherence to multidisciplinary team review was 75.0%, and surgical management was performed in 70.7% of patients meeting an indication for surgery. Conclusion: IE mortality rates remain high, particularly in patients who do not undergo surgical management. Streamlined MDT assessment and referral for surgical management where appropriate is necessary to improve outcomes. [ABSTRACT FROM AUTHOR]

Up to 14% of endometrial cancers and 23% of epithelial ovarian cancers are associated with genetic predispositions. Referral for genetic testing and counseling can significantly impact a patient's oncologic outcomes. However, significant disparities in genetic referral and testing exist within medically underserved and minority populations in the United States. These disparities in care and access to care are multifactorial, often involving patient-level, health care-level, and system-level factors. In this review, we focus on disparities in genetic testing among patients with ovarian and uterine cancer, and the missed opportunities for primary cancer prevention among their relatives. [ABSTRACT FROM AUTHOR]

Aim: This study investigated the impact of coronavirus disease 2019 (COVID‐19) on the clinical characteristics and interregional movement of patients with uterine cervical cancer. Methods: This study included 1189 patients who underwent treatment for cervical cancer, including cervical intraepithelial neoplasm and adenocarcinoma in situ, at our hospital in Tokyo, Japan, in 2017–2018 and in 2021, before and after the pandemic, respectively. The patients' clinical information was compared during both periods. The clinical stage was unified using the International Federation of Gynecology and Obstetrics (FIGO) 2008 staging. Results: The number of patients treated for cervical cancer was 355, 420, and 414 in 2017, 2018, and 2021, respectively. The percentage of invasive carcinomas significantly increased from 158 (44.5%) and 196 (46.7%) to 219 (52.9%) (p = 0.049). In all periods, no significant differences were observed in median age, histological type, and treatment. The proportions of FIGO Stage IA1 were significantly elevated from 3.9% and 3.8% to 11.4% (p < 0.001). The percentage of patients from prefectures other than Tokyo significantly increased from 34.9% to 40.8% (p = 0.049). Furthermore, the proportion of patients with invasive carcinoma in private clinics increased from 28.0% to 37.9% (p = 0.014). Conclusions: The number of patients with invasive carcinoma and the percentage of patients with invasive carcinoma referred from private clinics increased, indicating that the COVID‐19 pandemic influenced patients to delay consultations. Furthermore, the surge in patients from other prefectures indicates that medical resources were more limited in rural areas, another impact of COVID‐19. [ABSTRACT FROM AUTHOR]

Purpose: Brief Admission by self-referral (BA) is a standardized crisis-management intervention for individuals with self-harm and risk for suicide. This study explored relatives' experiences of BA. Relatives' perspectives may contribute to an increased understanding of the effects of BA given the relatives' role as support and informal caregivers as well as being co-sufferers. Methods: Fourteen relatives to adults with access to BA within one Swedish region participated in focus groups analysed with reflexive thematic analysis. Results: We generated themes evolving around three meaning-based concepts: access (A low threshold to a safe back-up is crucial and obstacles may easily break faith), independence (Trust in their ability with care and respect), and recovery (The rest and relational recovery we all get are needed and invaluable). Conclusions: BA brings considerable value to users and relatives, by supporting them to take care of themselves and each other. Communication and involvement of relatives may enhance users' ability to overcome obstacles to accessing BA. Implementation and adherence may be strengthened by supervision of BA staff and education of emergency care staff. Resources are needed to improve access. Mapping hurdles to BA, support through peers and targeted psychoeducation may improve recovery for BA users and their relatives. [ABSTRACT FROM AUTHOR]

Purpose: Multiple knowledge sources inform healthcare. In healthcare encounters, patients and health professionals' ideas intersect to understand illness and disease. Exploring what is thought of as legitimate knowledge, and where those reflections come from is central to the process of improving and developing healthcare. Within this context, we aim to explore how knowledge about hand osteoarthritis (OA) is constructed and negotiated in clinical consultations. Methodology: The article is based on interviews with 21 patients and 14 health professionals in combination with observation in 16 clinical consultations. Reflexive thematic analysis was used to interpret the data. Results: We generated four themes from codes to tell an interpretive story about how hand OA meaning-making is "talked into being" in patient-provider encounters: from the dominant voice of health professionals, from patients as knowers in the chronic healthcare dialogue, from health professionals and patients constructing knowledge together and from the construction of knowledge in hybrid positions when patients are health professionals and health professionals have hand OA. Conclusion: New knowledge about hand OA is co-constructed in the situated context of the clinical encounter through a polyphony of voices—some of which are dominant, while others occupy the periphery—within and between the interactants in dialgue. [ABSTRACT FROM AUTHOR]

This study sought to validate the HLS 19 -Q12 in Spain and in the Spanish language, as well as describe the sociodemographic profile and the general health literacy of the study population. Descriptive cross-sectional. Factor analysis and Cronbach's alpha were used to validate the Spanish version of the HLS 19 -Q12. Health literacy scores and associated categories were calculated using the scale factsheet, and the patient population sociodemographic profile was determined using frequency analysis. The HLS 19 -Q12 used in Spain in the Spanish language was found to be both valid and reliable (Cronbach's alpha = 0.87). The sociodemographic profile was primarily male and aged, and the majority of patients were of Spanish origin and had diabetes. General patient health literacy was limited, with 60% of participants having general health literacy categorized as inadequate or problematic, and 40 % sufficient or excellent. This study validated the HLS 19 -Q12 in Spain, created a sociodemographic profile of the sample population, and calculated their health literacy scores. This contribution provides another valuable validated tool and associated data to the increasingly important field of health literacy. [ABSTRACT FROM AUTHOR]

Aim: To examine the role of nurse–patient mutuality on three self‐care behaviours in chronic illness patients. Design: A cross‐sectional multi‐centre study was conducted. Methods: Mutuality was measured with the Nurse–Patient Mutuality in Chronic Illness scale which has the dimensions of developing and going beyond, being a point of reference and deciding and sharing care, and self‐care was measured with the Self‐care of Chronic Illness Inventory (SC‐CII). Multivariable linear regression analyses were used to assess the contribution of three dimensions of mutuality on self‐care maintenance, monitoring and management behaviours controlling for patient gender, age, education, number of medications, and presence of a family caregiver. Results: The sample included 465 inpatients and outpatients with at least one chronic illness. The three dimensions of mutuality had different roles in their influence on the three dimensions of self‐care. Developing and going beyond was significantly associated with self‐care maintenance and self‐care monitoring behaviours. Point of reference was significantly associated with self‐care maintenance behaviour. Deciding and sharing care was significantly associated with self‐care monitoring and self‐care management behaviours. Conclusion: The mutuality between nurse and patient may be a novel area of research to support and improve patient self‐care behaviours with implications for clinical practice and education. Implication for Profession and Patient Care: Mutuality between nurse and patient increases patient engagement, symptom recognition, decision‐making process and patient‐centred approach favouring the development of self‐care behaviours. Impact: Mutuality between nurse and patient is a new concept and its association with the patient outcomes could bring relevance to the nursing profession. Self‐care behaviours are important in the management of chronic diseases, but are difficult to perform. Mutuality between nurse and patient influences the three different behaviours of self‐care in chronic illness, for this reason it is important to increase the level of mutuality in this dyad. Reporting Method: STROBE checklist for cross‐sectional studies was followed in this study. Patient or Public Contribution: Patients were involved in the sample of the study. [ABSTRACT FROM AUTHOR]

Diagnosis with cancer can be a shocking, life-altering, and traumatic experience for both the affected patient and their family, which may include immediate or extended family, significant others, and caregivers. Living with or surviving cancer can negatively impact the patient and their family members individually, and it can also result in negative effects on the patient-family dyad. In the US alone, the American Cancer Society anticipates approximately 2 million new cases of cancer in 2024; moreover, as many as 25% to 30% of cancer survivors experience anxiety, depression, and posttraumatic stress disorder. Although healthcare providers are often pressed for time during routine initial and follow-up appointments, exploration of the person with cancer's journey through the disease course must be a priority and a collaborative effort. Prompt identification of mental health disorders, including substance use disorders, in people with cancer and their family members is essential to the well-being of the dyad. Many primary care providers provide both primary care services and survivorship care, such as posttreatment preexisting and secondary cancer surveillance, to cancer survivors. Primary care NPs are therefore well positioned to screen, assess, and treat mental health conditions in the cancer survivor and their family. The primary care NP also may have a greater opportunity to interface with patients' family members, thereby promoting healthier families and societies. Living with or surviving cancer can negatively impact the patient and their family members individually, and it can also result in negative effects on the patient-family dyad. Exploration of the person with cancer's journey through the disease course must be a priority and a collaborative effort. Prompt identification of mental health disorders is essential to the well-being of the dyad. Primary care NPs are well positioned to screen, assess, and treat mental health conditions in the cancer survivor and their family. [ABSTRACT FROM AUTHOR]

Background: The incidence of chronic disease is increasing worldwide which, in turn, increases the demand for healthcare services. To meet these demands, healthcare systems are adapting their services in order to reduce treatment costs and ensure coherence for patients with multiple diseases. One form of adaptation is shared outpatient consultations between internal medical specialties. However, little is known about how patients interact with multiple clinicians in shared consultations. Aim: This project aimed to explore how patients with diabetes and chronic kidney disease interact with multiple clinicians in a shared outpatient setting. Research Methods: We performed a qualitative ethnographic study, combining focused participant observations with informal field interviews. We included 17 participants, nine males and eight females with a mean age of 67.3 in the project. The data analysis was guided by Braun and Clarke's reflexive thematic analysis and Arthur Kleinman's theory of illness and disease. Results: We found one over‐arching theme: 'A consultation which encompassed both illness and disease' and four subthemes: (1) 'The medical focal point' pertained to the focus on physiological measurements in dialogue between patients and clinicians. (2) 'The possibility of negotiations' illustrated how decisions about dialysis and pharmacological treatment were based on negotiations. (3) 'Speaking different languages' displayed how patients used alternative illness‐based explanations whereas clinicians tended to use biomedical language. (4) 'Perceptions of everyday life' concerned what patients considered was best for them when managing their illness and everyday lives. Conclusion: Patients present information on how they balance life with physiological and psychosocial challenges. When clinicians employ a biomedical perspective, opportunities to gain information on patients' illness behaviours or cues to negotiate are missed. Patients prioritise functioning on a daily level over following treatment regimes. These findings are tenuous and require verification in similar studies in similar settings. Short Phrases: Shared Outpatient Clinic, Patient–clinician interactions. [ABSTRACT FROM AUTHOR]

Substance use is a persistent concern for adolescents in many countries due to the significant negative impact on mental, physical and social outcomes. US research indicates that while 4.1% of 12–17‐year‐olds require treatment, <10% of those who require it access it. This paper summarises the literature available on the barriers and enablers to those under 18s attending substance use treatment to inform policy and practice. Using a systematic approach, we searched six databases for studies which reported barriers and enablers to those aged 18 and under accessing substance use treatment. Thirty‐two papers met the inclusion criteria and we present the findings using a narrative synthesis. Only one paper identified explored this topic in Europe. Barriers and enablers are presented across four themes: (1) individual factors, (2) societal factors, (3) Gateway Providers and (4) treatment service factors. Mental health nurses, especially those working with young people, should be aware that adolescents are unlikely to perceive their substance use as problematic and rely on adults to access treatment. Access appears more difficult for females and socially marginalised youth. Various professionals direct young people towards treatment, but clear protocols are needed to encourage them to intervene, which could be an opportunity for nurses to be innovative and lead in this area. Services perceived as adolescent‐specific, youth‐friendly and flexible encourage attendance while the cost of treatment, including time off work and transport, function as barriers. [ABSTRACT FROM AUTHOR]

Background and aims: Alcohol use disorder (AUD) is characterized by low levels of engagement with effective treatments. Enhancing awareness of AUD treatments and how to navigate the treatment system is crucial. Many individuals use online sources (e.g. search engines) for answers to health‐related questions; web‐based results include a mix of high‐ and low‐quality information. Artificial intelligence may improve access to quality health information by providing concise, high‐quality responses to complex health‐related questions. This study evaluated the quality of ChatGPT‐4 responses to AUD‐related queries. Method: A comprehensive list of 64 AUD‐related questions was developed through a combination of Google Trends analysis and expert consultation. ChatGPT‐4 was prompted with each question, followed by a request to provide 3–5 peer‐reviewed scientific citations supporting each response. Responses were evaluated for whether they were evidence‐based, provided a referral and provided supporting documentation. Results: ChatGPT‐4 responded to all AUD‐related queries, with 92.2% (59/64) of responses being fully evidence‐based. Although only 12.5% (8/64) of responses included referrals to external resources, all responses (100%; 5/5) to location‐specific ('near me') queries directed individuals to appropriate resources like the NIAAA Treatment Navigator. Most (85.9%; 55/64) responses to the follow‐up question provided supporting documentation. Conclusions: ChatGPT‐4 responds to alcohol use disorder‐related questions with evidence‐based information and supporting documentation. ChatGPT‐4 could be promoted as a reasonable resource for those looking online for alcohol use disorder‐related information. [ABSTRACT FROM AUTHOR]

Background and Aims: Pathways of transitioning from tobacco smoking to vaping after receiving an e‐cigarette‐based smoking cessation intervention have been minimally explored. Study aims: 1) identify pathways between intervention delivery and final follow‐up; 2) describe baseline and post‐intervention statistical data in relation to smoking/vaping behaviour of the different pathway groups; 3) explore qualitative participant perspectives contextualising pathway groups. Design: Embedded mixed‐methods analysis of data collected for the Cessation of Smoking Trial in the Emergency Department (COSTED) randomised controlled trial. Setting: Recruitment from 6 Emergency Departments (5 in England and 1 in Scotland) between January and August 2022. Participants: 366 adult smokers who were randomised to receive the COSTED intervention and provided data at 6‐month follow‐up. Qualitative subsample of 24 participants interviewed after follow‐up. Interventions: Brief smoking cessation advice, provision of an e‐cigarette starter kit and referral to the local Stop Smoking Service. Measurements: Descriptive statistical reporting of identified pathways and smoking/vaping behaviour at baseline and 6‐month follow‐up. Semi‐structured phone/video interviews analysed thematically. Findings 13.4% (n = 49) of participants quit smoking within 1 month of receiving the intervention, 19.1% (n = 70) quit between 1 and 6 months, 24.9% (n = 91) reduced cigarettes per day (CPD) by at least 50%, and 42.6% did not experience a significant smoking reduction. Approximately a third of participants who quit reported not vaping at follow‐up. Reporting dual use was associated with a reduction in CPD. Appoximately a third reported experimenting with a different device to the one provided as part of the intervention. Quitters reported themes of satisfaction with vaping, changes in environment facilitating quitting and motivation to quit. Conclusions: Dual use of cigarettes and e‐cigarettes can result in a reduction of smoking and may prelude quitting smoking. Sustained e‐cigarette use is not always necessary for quitting success. Success depends on personal context as well satisfaction with vaping. [ABSTRACT FROM AUTHOR]

Objective: To determine the associations between lid and conjunctival injuries (LACI), non‐fatal strangulation (NFS) and domestic family violence (DFV) in non‐sexual assault. Methods: The present study involves an analysis of LACI in a clinical audit of 85 sequential non‐sexual assault presentations. Results: LACI was present in 26.9% of non‐sexual assault cases, and 47.4% of LACI patients also experienced NFS. LACI was sustained in the context of DFV in 62.9% of cases. Females made up 69.2% of LACI patients, with those between 14 and 29 years most at risk. Children were present in 12.8% of cases, 78.2% of perpetrators were male and 44.9% of patients had previously been assaulted by the same perpetrator. Conclusions: LACI is frequently associated with NFS and/or DFV. Since NFS increases future homicide attempts and events more than sixfold, LACI is an important signal about a patient's homicide risk, expanding the dimensions of the care needed. Those experiencing LACI during an assault also need to be referred for comprehensive eye examination as soon as possible. With consent, systematic forensic photography of LACI enables its assessment and documentation, which assists the legal process. These conclusions should drive legislative consideration and reform, plus expanded education for clinicians and police. [ABSTRACT FROM AUTHOR]

Objective: Antipsychotics remain the first‐line treatment for people diagnosed with psychotic disorders despite adverse effects which lead many people to stop their medication. Many stop without the support of the prescriber, who may fear relapse. The objective of this study is to better understand the process of withdrawal from antipsychotics, from the perspective of people taking antipsychotics. Design: Online survey. Methods: An international online survey elicited quantitative responses about pre‐withdrawal planning (560) and qualitative responses about what was helpful and unhelpful when withdrawing from antipsychotics (443). Responses came from users of antipsychotics in 29 countries. Results: Forty‐seven per cent did not consult their psychiatrist before discontinuing. Only 40% made preparations, most commonly making a plan, gathering information and informing family. The most frequently reported helpful factors were focussing on the benefits of getting off the drugs (including ending adverse effects and feeling more alive), information about withdrawal symptoms and how to withdraw safely, withdrawing slowly, and support from psychologists, counsellors and psychotherapists. The most common unhelpful factor was the psychiatrist/doctor, largely because of their lack of knowledge, refusal to support the patient's wishes and the threat or use of coercion. Conclusions: Evidence‐based, respectful, collaborative responses to patients' concerns about adverse effects and desires to withdraw would probably reduce relapse rates and improve long‐term outcomes. It would definitely help end pervasive breaching of the principle of informed consent and human rights legislation. [ABSTRACT FROM AUTHOR]

PURPOSE: Patients with cancer frequently undergo research-grade germline sequencing but clinically actionable results are not routinely disclosed. The objective of this study is to evaluate the feasibility of reporting clinically relevant secondary findings (SF) identified in germline research sequencing using the institutional molecular tumor board (MTB) and the treating oncology physician. METHODS: This prospective, interventional cohort study enrolled Total Cancer Care participants with any cancer diagnosis at a single institution. Patients underwent research-grade germline whole-exome sequencing, with bioinformatic analysis in a Clinical Laboratory Improvement Amendments–certified laboratory to verify pathogenic/likely pathogenic germline variants (PGVs) in any American College of Medical Genomics and Genetics SF v2.0 genes. After a protocol modification in consenting patients, the MTB reported PGVs to treating oncology physicians with recommendations for referral to a licensed genetic counselor and clinical confirmatory testing. RESULTS: Of the 781 enrolled participants, 32 (4.1%) harbored cancer predisposition PGVs, 24 (3.1%) were heterozygous carriers of an autosomal recessive cancer predisposition syndrome, and 14 (1.8%) had other hereditary disease PGVs. Guideline-directed testing would have missed 37.5% (12/32) of the inherited cancer predisposition PGVs, which included BRCA1 , BRCA2 , MSH6 , SDHAF2 , SDHB , and TP53 variants. Three hundred fifteen participants consented to reporting results; results for all living patients were reported to the clinical team with half referred to a licensed genetic counselor. There was concordance between all research variants identified in patients (n = 9) who underwent clinical confirmatory sequencing. CONCLUSION: MTB reporting of research-grade germline sequencing to the clinical oncology team is feasible. Over a third of PGVs identified using a universal testing strategy would have been missed by guideline-based approach, suggesting a role for expanding germline testing. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations. Design: A retrospective register-based follow-up cohort study. Setting: Public primary health care in the City of Vantaa, Finland. Subjects: All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014. Main outcome measures: Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department. Results: Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3–1.7) to 10.5 (10.3–12.2) (p < 0.001) and registered nurse consultations from a median of 3.6 (3.0–4.0) to 14.5 (13.0–16.6) (p < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses. Conclusions: It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care. KEY POINTS: The number of general practitioner (GP) consultations are decreasing. Tasks are being transferred from GPs to nurses to improve access to care. The number of office-hour consultations with nurses did not change, despite the decrease in GP consultations. In the emergency department, the number of nurse consultations increased significantly when GP consultations decreased. Medical consultations seem to have shifted to the emergency department and the nurses. [ABSTRACT FROM AUTHOR]

Background: According to the UN Committee Against Torture, all state parties to the Torture Convention have a responsibility to meet the rehabilitation needs of torture victims who have sought asylum within their borders. General practitioners (GPs) can play a crucial role in identifying torture victims and securing rehabilitation when needed. There is a pressing knowledge gap on the knowledge and practices of GPs vis-à-vis potentially tortured patients, and an urgent need for research that investigates GPs' practices of identification, referral, and rehabilitation – in Norway and beyond. This article presents an exploratory qualitative pilot study that investigates the experiences of GPs in Oslo vis-à-vis this patient group. Methods: Semi-structured interviews with five experienced GPs in the greater Oslo area. Interview data was analyzed through thematic analysis and discussed within a theoretical framework seeing GPs as street-level bureaucrats. Results: Issues that emerged in the pilot involve a consistent professional confidence and a particular concern for victims of sexual violence and sexualized torture. The pilot also found a troubling commonsensical reasoning about identification in the asylum process. The GPs asked for the re-establishment of specialist rehabilitation centers for refugees and torture victims to consult in case of need. Alas, the study also confirmed that GPs are a difficult profession to recruit for research. Conclusions: This study indicates that GPs are important actors in terms of identifying torture victims after resettlement, but that there are shortcomings in their training and knowledge, in the overall organization of the healthcare system, and in specialized healthcare, that limit prospects for rehabilitation. KEY POINTS: To what extent are torture victims met or identified by GPs in resettling contexts? This paper presents a pilot study designed to address this knowledge gap and prepare future studies. We found: GPs were confident in their abilities to identify and meet torture victims in a good way – and in the value that is patient-doctor continuity in general medicine. Troubling commonsensical reasoning about identification in the asylum process and in consultations. A lack of and need for qualified and available expertise to consult with and/or refer tortured patients to. [ABSTRACT FROM AUTHOR]

Objective: Private health insurance is becoming more common in Norway. The aim of this study was to investigate GPs' opinions on private health insurance, and their experiences from consultations where health insurance can affect decisions about referring. Design: A web based cross-sectional survey. Setting: Norwegian general practice. Subjects: All GPs in Norway were in 2019 invited to participate in an online survey. Main outcome measures: The GPs' opinions and experiences regarding health insurance were reported as proportions. Multiple logistic regression was used to test associations between how frequently GPs refer patients without further considerations and variables concerning their characteristics, opinions, and experiences. Results: Of 1,309 GPs (response rate 27%), 93% stated that private health insurance raises the risk of overtreatment and 90% considered such insurance to contribute to inequality in health. Frequently being pressured to refer in the absence of a medical indication was reported by 42%. Moreover, 28% often or always chose to refer patients without further consideration, and this was associated with perceptions of pressure with an adjusted odds ratio (AOR) of 3.80, 95% confidence interval (CI) 2.73–5.29, and unpleasant reactions from patients following refusals (AOR 1.63, 95% CI 1.14–2.33). Conclusion: Although most participating GPs associated private health insurance with overtreatment and inequality in health, more than one in four choose to refer without further consideration. GPs' experience of pressure to refer and negative reactions from patients when they consider referrals not to be medically indicated, raises the risk of medical overuse for patients holding private health insurance. KEY POINTS: Although most GPs had negative opinions regarding private health insurance, more than one quarter frequently referred insurance holders without further considerations. Perceived pressure and negative reactions from patients were associated with accommodating requests rather than acting as a gatekeeper. Private health insurance challenges the gatekeeping role of GPs in Norway and raises the risk of medical overuse. [ABSTRACT FROM AUTHOR]

Objective: Describe trends in health care utilization, demographic characteristics and patient pathways among patients with musculoskeletal disorders (MSD) in Norway. Design: Register-based cohort study. Settings: Data were obtained from two Norwegian National registries; the Norwegian Control and Payment of Health Reimbursements Database (KUHR) and the Norwegian Patient Registry (NPR). Subjects: Patients with MSD according to ICPC-2 and ICD-10 during 2014–2017. Main outcome measures: Patient pathways from the first contact and the following two years, described in a Sankey Diagram for all MSD patients and three common diagnoses: spine pain, osteoarthritis (OA) and fibromyalgia (FM). Result: About 26% of the Norwegian population consulted PHC annually while 7% were treated in SHC. Mean age was 47 and 53 years in PHC and SHC, respectively. The proportion of women increased by age. Spine pain was the most common diagnosis; 33% and 22% in PHC and SHC, respectively. Over 90% visited a GP first, 50% of them were treated by PT and/or in SHC during follow-up. Patients visiting the PT first were less likely to be treated in SHC. OA patients were most likely to be treated by more than one health care professional (>70%). Conclusion: One third of the Norwegian population consulted health care services due to MSD annually between 2014–2017. GP was the most consulted health care professional. Among MSD patients with long-term use of health care services, 50% were treated by a PT and/or in SHC in addition to a GP. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to survey general practitioners' (GPs) and radiologists' perspectives on referrals, imaging justification, and unnecessary imaging in Norway. Materials and methods: The survey covered access to imaging, responsibilities, attitudes toward justification assessment, referral process, and demographics using multiple choice questions, statements to report agreement with using the Likert scale and one open question. Results: Forty radiologists and 58 GPs attending national conferences completed a web-based survey, with a 20/15% response rate, respectively. Both radiologists (97%) and GPs (100%) considered avoiding unnecessary examinations essential to their role in the healthcare service. Still, 91% of GPs admitted that they referred to imaging they thought was not helpful, while about 60% of the radiologists agreed that unnecessary imaging was conducted in their workplace. GPs reported pressure from patients and patients having private insurance as the most common reasons for doing unnecessary examinations. In contrast, radiologists reported a lack of clinical information and the inability to discuss patient cases with the GPs as the most common reasons. Conclusion: This study adds to our understanding of radiologists' and GPs' perspectives on unnecessary imaging and referrals. Better guidelines and, even more importantly, better communication between the referrer and the radiologist are needed. Addressing these issues can reduce unnecessary imaging and improve the quality and safety of care. [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]

Nearly 60% of people with HIV in New York State are over 50 years of age. After town halls and a statewide survey of long-term survivors, older people living with HIV, and their providers, the Quality of Care Program of the AIDS Institute in the New York State Department of Health developed a statewide quality improvement project that aimed to improve screening for functional impairments among people aging with HIV. Thirteen sites reported outcomes of a pilot project using a modification of the World Health Organization's Integrated Care of Older People (ICOPE) intrinsic capacity screen in small scale, short cycle tests of change. A total of 1,629 people were found to be eligible for screening, and of these, 638 people were screened. Both clinical and non-clinical sites were able to identify significant areas of need. Positive screens ranged from a low of 17% for the identification of hearing issues to 49% for vision concerns. Only 11% of people with memory or nutritional concerns were referred for services; hearing loss was the domain with the largest number of referrals, at 27%. Although in many cases, when referrals were not made, patients/clients were already under care for the identified functional deficit, in other cases no services were available for referral or patients/clients declined to use the offered service. Sites also responded to the findings of the screen by initiating process changes, and many reported continuing to screen for functional impairments after the close of the pilot. The modified ICOPE screen is still in use in sites throughout the state. This pilot demonstrated that a collaboration between people with lived HIV experience, the New York State Department of Health, clinicians, and service providers could result in improved quality of care for people aging with HIV. [ABSTRACT FROM AUTHOR]

Musculoskeletal conditions in children frequently lead to referrals to paediatric orthopaedic clinics, driven by anxiety among parents and primary care providers. Normal variants, which represent a substantial proportion of these referrals, require thorough understanding to distinguish them from pathologic conditions and provide appropriate reassurance. This review outlines common normal variants and disorders of growth, categorized by presenting complaints, anatomical location, and age group. Effective management often involves parental reassurance, observation, and conservative measures such as physiotherapy and activity modification. Surgical interventions are rarely required. Emphasizing the importance of collaboration between paediatric orthopaedic surgeons and primary care providers, this review highlights the importance of musculoskeletal education to reduce unnecessary referrals and optimize patient care. [ABSTRACT FROM AUTHOR]

Despite initiatives to increase palliative care awareness, referrals in primary care settings are still primarily based on provider judgment, causing a lack of appropriate referrals and disparities in access to palliative care resources. The purpose of this quality improvement project was to develop and implement an evidence-based, standardized palliative care referral protocol to increase the palliative care referral rate for eligible patients at a primary care clinic. The project used a preimplementation and postimplementation design with the use of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to successfully implement and evaluate the standardized referral process. Over the 10-month project period, the palliative care referral rate increased from 2% (4/193) preimplementation to 11% (16/147) postimplementation of the standardized referral process, which is an increase of 9%. Taking into consideration the potential impact of multiple extraneous variables, there was an overall decrease of 69% in emergency room visits and 73% in hospitalizations for patients who received a palliative care referral. These outcomes support expansion of the standardized referral process throughout other primary care clinics to increase palliative care referrals and sustain a high level of quality patient care. [ABSTRACT FROM AUTHOR]

This collaborative study by The Australasian College of Paramedicine's Clinical Practice Guidelines (CPG) Working Group aimed to examine CPG development practices in Australian and New Zealand ambulance services. Employing a qualitative descriptive design, the research utilised thematic analysis to extract insights from interviews with eleven experts actively involved in CPG development. The study embraced a nominalist and constructivist approach, recognising the intricate connection between individual experiences and the realities of CPG development in the paramedic field. Key findings revealed significant heterogeneity in CPG development practices, emphasising a lack of formal training and a substantial reliance on existing guidelines. The study highlighted challenges in project management flexibility, limited research capacity, and inconsistencies in external consultations and resource utilisation. The study recommends adopting project management frameworks, investing in training, and utilising evidence evaluation methodologies like GRADE. It emphasises the need for multidisciplinary teams and formal expertise in evidence synthesis, advocating for targeted training programs. Funding challenges highlight the importance of dedicated budgets and collaborative efforts for resource allocation. Knowledge translation and implementation issues underscore the significance of training programs for evidence evaluation and knowledge translation in overcoming these challenges. [ABSTRACT FROM AUTHOR]

The epidemic of opioid overdose brought a major health crisis to the front line of public health in the United States. Early efforts have focused on the prevention of production, distribution, and consumption of the drugs. However, there is little information about youth populations at risk for opioid overdose and their response to targeted treatment plans. The San Bernardino County Youth Opioid Response (SBCYOR) coalition in collaboration with the San Bernadino County (SBC) Probation Department organized a safety net system for at-risk youth by improving communication among county resources. This program mainly focused on individuals aged 12 to 24 years in the county's detention centers along with educational and prevention projects such as naloxone programs for first responders in the region. To describe the impact of the SBCYOR program on at-risk youth, we compare the frequencies of patients referred and treated with medications for opioid use disorder (MOUD) at the SBC Probation Department, which was responsible for individuals from age 12 to less than 18 years, with those from the West Valley Detention Center (WVDC), which was responsible for adults (18 to 24 years of age), from September 2020 through June 2022. Similar proportions of youths were referred for treatment of opioid use disorder (OUD) at the respective sites (3.7% SBC Probation Department, 3.6% WVDC). Of these, however, 78.0% were treated with MOUD at SBC Probation Department compared with only 7.1% at WVDC. SBCYOR coalition partners were able to transform their services into a comprehensive medical and behavioral health program for the incarcerated youth population at risk for OUD. [ABSTRACT FROM AUTHOR]

PURPOSE: Less than half of the patients with newly diagnosed metastatic non–small cell lung cancer (NSCLC) undergo comprehensive molecular testing. We designed an electronic medical record (EMR)–based "nudge intervention" to prompt plasma-based molecular testing at the time of initial medical oncology consultation. METHODS: A nonrandomized prospective trial was conducted at the University of Pennsylvania's academic practice and two affiliated community practices. Molecular genotyping was performed by tissue- and/or plasma-based next generation sequencing methods. Comprehensive testing was defined as testing for EGFR , ALK , BRAF , ROS1 , MET , RET , KRAS , and NTRK. Guideline-concordant treatment was defined as the use of the appropriate first-line (1L) therapy as per the National Comprehensive Cancer Network (NCCN) guidelines. Proportion of patients with comprehensive molecular genotyping results available at any time, molecular results available before 1L therapy, and guideline-concordant 1L treatment were compared between the preintervention and postintervention cohorts using Fisher's exact test or Pearson's chi-squared test. RESULTS: Five hundred and thirty-three patients were included, 376 in the preintervention cohort and 157 in the postintervention cohort. After implementation of the EMR-based nudge, a higher proportion of patients underwent comprehensive molecular testing in the postintervention versus the preintervention cohort (100% v 88%, P = <.001), had results of comprehensive molecular testing available before initiating 1L treatment (97.3% v 91.6%, P =.026), and received NCCN guideline-concordant care (89.8% v 78.2%, P =.035). CONCLUSION: Across three practice sites in a large health system, implementation of a provider team–focused EMR-based nudge intervention was feasible, and led to a higher number of patients with NSCLC undergoing comprehensive molecular genotyping. These findings demonstrate that behavioral nudges can promote molecular testing and should be studied further as a tool to improve guideline-concordant care in both community and academic sites. [ABSTRACT FROM AUTHOR]

For women diagnosed with cancer, side effects affecting their sexuality are extremely common and can be distressing and life-changing; however, most women are left in the dark without any guidance from their oncology teams regarding possible side effects and treatment options. American Society of Clinical Oncology clinical guidelines provide guidance on the recommended assessments related to the domains of sexual function and their respective interventions. Despite the existence of these guidelines, the reality is that only a few women with cancer are asked about sexual concerns that result from cancer treatments. Common barriers to sexuality discussion reported by oncology providers include a lack of qualification and knowledge, not having a place to refer patients, and not knowing how to start the conversation. Social media remains a widely untapped resource regarding sexuality and cancer interventions, as people are increasingly turning to social media for health information and advice. This may be especially relevant for sexuality, as oncologists may not feel comfortable or well-trained to discuss the topic, and patients may be reluctant to bring up sexual concerns during their visits. Social media can play a critical role in studying sexual health and in sexuality interventions, particularly in adolescent and young adult patients with cancer. Here, we discuss the lack of inclusion regarding sexuality in oncology, the rates of sexual dysfunction in patients with cancer, treatment options for common sexual concerns, how to utilize the reach of various social media channels, and provide patient and provider resources. [ABSTRACT FROM AUTHOR]

Since the complexities of commissioning medical laboratory tests have grown continuously as a result of the increase in specialised forms of care, this article aims to create a practice-oriented structure of the legal and procedural requirements and to illustrate these using case studies – specifically using the example of so-called ambulatory medical specialist care (ASV) in accordance with Par. 116b SGB V and selected selective contracts in accordance with Par. 140a SGB V. Even if the system of correct laboratory billing described in our previous articles has remained largely valid, we believe that structuring specialised forms of care in the outpatient sector would be particularly helpful. In addition to our previous articles on the system of correct laboratory billing, it is shown that laboratory commissioning must also be systematically correct and that all parties involved in the process (doctor's surgeries, clinics, medical laboratories and insured persons) will benefit from this. In doing so, we are developing a system for correct laboratory ordering that leads to an improvement in process quality and process simplification when functionalised via so-called "order/entry"- or automated registration systems. [ABSTRACT FROM AUTHOR]

Background: To investigate the effectiveness of the intervention with critical value management and push short messaging service (SMS), and to determine improvement in the referral rate of patients with positive hepatitis C antibody (anti-HCV). Methods: No intervention was done for patients with positive anti-HCV screening results from 1 January 2015 to 31 October 2021. Patients with positive anti-HCV results at our hospital from 1 November 2021 to 31 July 2022 were informed vide critical value management and push SMS. For inpatients, a competent physician was requested to liaise with the infectious disease physician for consultation, and patients seen in the OPD (outpatient department) were asked to visit the liver disease clinic. The Chi-square correlation test, one-sided two-ratio test and linear regression were used to test the relationship between intervention and referral rate. Results: A total of 638,308 cases were tested for anti-hepatitis C virus (HCV) in our hospital and 5983 of them were positive. 51.8% of the referred patients were aged 18-59 years and 10.8% were aged ≥75 years. The result of Chi-square correlation test between intervention and referral was p = .0000, p < .05. One-sided two-ratio test was performed for statistics of pre-intervention referral rate (p1) and post-intervention referral rate (p2). Normal approximation and Fisher's exact test for the results obtained were 0.000, p < .05, and the alternative hypothesis p1 - p2 < 0 was accepted. The linear regression equation was referral = 0.1396 x intervention + 0.3743, and the result model p = 8.79e-09, p < .05. The model was significant, and the coefficient of intervention was 0.1396. Conclusions: The interventions of critical value management and push SMS were correlated with the referral rate of patients with positive anti-HCV. [ABSTRACT FROM AUTHOR]