Composição da microbiota intestinal durante a gestação e puerpério em mulheres com diferentes intensidades de sintomas depressivos / Composition of Gut Microbiota During Pregnancy and Postpartum in Women with Varying Degrees of Depressive Symptoms

Os sintomas depressivos durante a gravidez e o período pós-parto (PP) são prevalentes e podem ter implicações profundas para o bem-estar materno e infantil. Evidências emergentes sugerem que a microbiota intestinal pode desempenhar um papel na regulação do humor. Este estudo explora a relação entre a composição da microbiota intestinal e os sintomas depressivos em mulheres grávidas e no pós-parto com diferentes intensidade de sintomas. Foram recrutadas gestantes que faziam acompanhamento nos hospitais HCFMUSP e HU- USP. A partir do preenchimento do questionário de Escala de Edimburgo as participantes foram triadas para os grupos de sintomas ausentes ou leves (AL) e sintomas graves ou moderados (MG). Para a análise de microbiota, as participantes forneceram amostras de fezes em três momentos diferentes. Uma no terceiro trimestre de gestação (G) e duas no período pós-parto. A primeira amostra deste período foi coletada durante a internação do pós-parto (P1), e a segunda durante a consulta de retorno um mês após o parto (P2). A composição da microbiota intestinal foi analisada usando técnicas de sequenciamento de alto rendimento e os ácidos graxos de cadeia curta (AGCC) foram quantificados por cromatografia gasosa acoplada à espectrometria de massas (GC-MS). Análises bioinformáticas e estatísticas foram realizadas utilizando os softwares QIIME 2 (2022.2) e R (4.3.1) para identificar possíveis associações entre a composição da microbiota intestinal e a gravidade dos sintomas depressivos. Os resultados indicam que a familia Enterobacteriacea aparece com maior abundância nas mulheres do grupo MG, especialmente durante o período P1 (p<0,05) e que há uma diminuição significativa (p<0,05) de sintomas depressivos nas participantes do grupo MG desde sua triagem até o fim do acompanhamento do estudo, indicando que conduta terapêutica está sendo eficaz. Apesar de não ter sido estabelecida diferença estatística na abundância relativa da microbiota entre os grupos durante a gestação e nos índices de alfa e beta diversidade entre grupos e entre os períodos, é possivel observar uma tendência de mudança de microbiota ao longo do tratamento com aumento do gênero Bifidobacterium, diminuição da familia Enterobacteraceae e é possivel observar uma aparente correlação inversa entre a diminuição da intensidade de sintomas depressivos e o aumento da abundância dos gêneros Bifidobacterium e Clostridium, além do aumento das concentrações de AGCC. Em conclusão, a composição da microbiota intestinal parece ser influenciada pela gravidade dos sintomas depressivos em mulheres grávidas e no pós-parto. Pesquisas adicionais são necessárias para explorar a relação entre a microbiota intestinal e a depressão perinatal e determinar as implicações clínicas dessas descobertas para a saúde materna e infantil.

Depressive symptoms during pregnancy and the postpartum period (PP) are prevalent and can have profound implications for maternal and infant well-being. Emerging evidence suggests that the gut microbiota may play a role in mood regulation. This study explores the relationship between gut microbiota composition and depressive symptoms in pregnant and postpartum women with different symptom severities. A cohort of pregnant women were recruited from HCFMUSP and HU-USP. Participants completed standardized depression assessment tools and were allocate in groups of absent or mild depressive symptoms (AL) and moderate or severe depressive symptoms (MG) and provided stool samples in three different time periods. One at the third gestation trimester (G) and two at the postpartum period. The first sample from this period was collected during postpartum hospitalization(P1), and the second during the onemonth postpartum follow-up appointment (P2). Their gut microbiota composition was analyzed using high-throughput sequencing techniques and Gas chromatography mass spectrometry (GS-MS) for quantification of short-chain fatty acids (SCFAs). Bioinformatic and statistical analyses were performed using softwares QIIME 2 (2022.2) and R (4.3.1) to identify potential associations between gut microbiota composition and depressive symptom severity. Findings that the Enterobacteriaceae family appears more abundantly in women of the MG group, especially during period P1 (p<0.05), and that there is a significant decrease (p<0.05) in depressive symptoms among the participants of the MG group from their screening to the end of the study follow-up, suggesting that the therapeutic approach is effective. Although no statistical differences in alpha and beta diversity indices were established between groups and across periods, it is possible to observe a trend of microbiota change during the treatment, with an increase in the Bifidobacterium genus, a decrease in the Enterobacteriaceae family, and an apparent inverse correlation between the reduction in the intensity of depressive symptoms and the increased abundance of the Bifidobacterium, Clostridium, and Dorea genera, as well as an increase in the concentrations of SCFAs. In conclusion, composition of gut microbiota appears to be influenced by the severity of depressive symptoms in pregnant and postpartum women. Further research is warranted to explore links between gut microbiota and perinatal depression and to determine the clinical implications of these findings for maternal and infant health

Assessing Telemedicine Efficiency in Follow-up Care With Video Consultations for Patients in Orthopedic and Trauma Surgery in Germany: Randomized Controlled Trial.

BACKGROUND: Telemedicine can help mitigate important health care challenges, such as demographic changes and the current COVID-19 pandemic, in high-income countries such as Germany. It gives physicians and patients the opportunity to interact via video consultations, regardless of their location, thus offering cost and time savings for both sides. OBJECTIVE: We aimed to investigate whether telemedicine can be implemented efficiently in the follow-up care for patients in orthopedic and trauma surgery, with respect to patient satisfaction, physician satisfaction, and quality of care. METHODS: We conducted a prospective randomized controlled trial in a German university hospital and enrolled 60 patients with different knee and shoulder conditions. For follow-up appointments, patients received either an in-person consultation in the clinic (control group) or a video consultation with their physician (telemedicine group). Patients' and physicians' subsequent evaluations of these follow-up appointments were collected and assessed using separate questionnaires. RESULTS: On the basis of data from 52 consultations after 8 withdrawals, it was found that patients were slightly more satisfied with video consultations (mean 1.58, SD 0.643) than with in-clinic consultations (mean 1.64, SD 0.569), although the difference was not statistically significant (P=.69). After excluding video consultations marred by technical problems, no significant difference was found in physician satisfaction between the groups (mean 1.47, SD 0.516 vs mean 1.32, SD 0.557; P=.31). Further analysis indicated that telemedicine can be applied to broader groups of patients and that patients who have prior experience with telemedicine are more willing to use telemedicine for follow-up care. CONCLUSIONS: Telemedicine can be an alternative and efficient form of follow-up care for patients in orthopedic and trauma surgery in Germany, and it has no significant disadvantages compared with in-person consultations in the clinic. TRIAL REGISTRATION: German Clinical Trials Register DRKS00023445; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023445.

Medical check-up of newly arrived unaccompanied minors: A dedicated pediatric consultation service in a hospital.

BACKGROUND AND AIMS: Healthcare for the increasing number of migrants in Europe, and particularly of unaccompanied minors (UMs) seeking asylum, has become a major challenge. We aimed to describe the health issues of UMs managed in a dedicated pediatric consultation service in a care center in Paris. METHODS: All UMs attending a dedicated migrant medical consultation service in Robert Debré Hospital, Paris, France, were included in a single-center retrospective observational study from September 1, 2017, to September 30, 2018. RESULTS: Out of the 107 UMs who were included, 87% had a health problem (n=93) and 52% had an infectious disease (n=56). The main infectious diagnoses were schistosomiasis (22%), latent tuberculosis (22%), intestinal parasitosis (16%), and chronic hepatitis B (8%). Posttraumatic stress disorder (PTSD) and overweight were common (35% and 20%, respectively). The median age was 15 years old (IQR, 14-16), the male/female ratio was 95/12. Most of the children were from sub-Saharan Africa (n=67), 46% had crossed Libya (n=49) and, when compared to the other migration routes, faced an increasing risk of violence (69%, p=0.04), imprisonment (53%, p=0.03), and forced labor (48%, p=0.02). The median duration of the trip before reaching France was 6 months (IQR, 2-13), the median time to consultation was 2 months (0-5) and was not associated with an increased risk of health problems. A total of 43 UMs were lost to follow-up. CONCLUSION: Health problems, particularly infectious diseases and PTSD, are common among UMs and should prompt an early medical consultation with psychiatric evaluation. Follow-up is problematic and could be improved by an on-line health book.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications.

OBJECTIVE: To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs). METHODS: The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission. RESULTS: During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission. CONCLUSIONS: The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study.

BACKGROUND: Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals' appropriateness. METHODS: Four inexperienced students (chiropractic master's students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or "other reasons" for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison. RESULTS: Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55-0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58-0.91) and 0.82 (95% CI: 0.72-0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters' results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84-92%, respectively, for the pairwise comparisons. CONCLUSION: The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

Profile of pharmaceutical care in primary health centers in São Bernardo do Campo, Southeastern Brazil

The effective insertion of the pharmacist into primary care is an important goal for health policies. The objective of this study was to describe and analyze pharmacists and Pharmaceutical Care in the primary health centers (UBS) of São Bernardo do Campo. Data were obtained through an interview applied to pharmacists. The instrument has three sections: (1) Pharmacist identification; (2) Pharmacist work; and (3) Pharmaceutical activities. Items in section 3 correspond to the guidelines of agencies that promote Pharmaceutical Care in the primary health system. All 24 pharmacists working in UBS in São Bernardo do Campo were interviewed. Every center dispensing medicines has a responsible pharmacist. These pharmacists are predominantly women and postgraduates. Activities of Pharmaceutical Care reported were: daily prescription analysis (75% of interviewees); monthly participation in patient groups (70.8%); monthly follow-up of pharmacotherapy adherence (58.3%); monthly participation in multiprofessional team meetings (54.2%); monthly home visits (12.5%); health education to the community (83.3%); and pharmacist consultation (37.5%). Frequency of prescription analysis and home visits was weakly associated with aspects of the pharmacist and the facility. This study showed that Pharmaceutical Services are structured in primary care in São Bernardo do Campo and many Pharmaceutical Care activities are offered in its UBS

A modified Delphi study to gain consensus for a taxonomy to report and classify physical activity referral schemes (PARS).

BACKGROUND: Physical Activity Referral Schemes (PARS), including exercise referral schemes, are a popular approach to health improvement, but understanding of effectiveness is limited by considerable heterogeneity in reporting and evaluation. We aimed to gain consensus for a PARS taxonomy as a comprehensive method for reporting and recording of such schemes. METHODS: We invited 62 experts from PARS policy, research and practice to complete a modified Delphi study. In round one, participants rated the need for a PARS taxonomy, the suitability of three proposed classification levels and commented on proposed elements. In round two, participants rated proposed taxonomy elements on an 11-point Likert scale. Elements scoring a median of ≥7, indicating high agreement, were included in the final taxonomy. RESULTS: Of those invited, 47 (75.8%) participated in round one, with high retention in round two (n = 43; 91.5%). 42 were UK-based, meaning the resultant taxonomy has been scrutinised for fit to the UK context only. The study gained consensus for a three-level taxonomy: Level 1: PARS classification (primary classification, provider, setting, conditions accepted [have or at risk of], activity type and funding). Level 2: scheme characteristics (staff structure, staff qualifications, behaviour change theories, behaviour change techniques, referral source, referrers, referral process, scheme duration, session frequency, session length, session times, session type, exit routes, action in case of non-attendance, baseline assessment, exit assessment, feedback to referrer and exclusion criteria) and Level 3: participant measures (demographics, monitoring and evaluation, and measures of change). CONCLUSION: Using a modified Delphi method, this study developed UK-based consensus on a PARS classification taxonomy. We encourage PARS practitioners and public health colleagues, especially those working with similar service models internationally, to test, refine and use this taxonomy to inform policy and practice.

Desarrollo de una aplicación para teléfonos móviles (app) basada en la colaboración Sociedad Española de Reumatología/Sociedad Española de Medicina de Familia y Comunitaria para derivación de enfermedades autoinmunes sistémicas / Development of an application for mobile phones (App) based on the collaboration between the Spanish Society of Rheumatology and Spanish Society of Family Medicine for the referral of systemic autoimmune diseases from primary care to rheumatology

El diagnóstico y tratamiento de las enfermedades autoinmunes sistémicas (EAS) constituye un reto. Aunque infrecuentes, afectan a cientos de miles de pacientes en España. El médico de familia (MF) se enfrenta a síntomas o signos inespecíficos que hacen sospechar EAS al inicio del proceso, y tiene que decidir a quiénes debería derivar. Para facilitar su reconocimiento y mejorar su derivación, expertos de la Sociedad Española de Medicina de Familia y Comunitaria y de la Sociedad Española de Reumatología seleccionaron 26 síntomas/signos-guía y alteraciones analíticas. Se escogieron parejas de MF y reumatólogo para elaborar algoritmos diagnósticos y de derivación. Posteriormente se revisaron y adaptaron al formato de aplicación para móviles (app) descargable. El resultado es el presente documento de derivación de EAS para MF en formato de papel y app. Contiene algoritmos de fácil manejo utilizando datos de la anamnesis, exploración física y pruebas analíticas accesibles en atención primaria para orientar el diagnóstico y facilitar la derivación a reumatología o a otras especialidades

Management of systemic autoimmune diseases is challenging for physicians in their clinical practice. Although not common, they affect thousands of patients in Spain. The family doctor faces patients with symptoms and non-specific cutaneous, mucous, joint, vascular signs or abnormal laboratory findings at the start of the disease process and has to determine when to refer patients to the specialist. To aid in disease detection and better referral, the Spanish Society of Rheumatology and the Spanish Society of Family Medicine has created a group of experts who selected 26 symptoms, key signs and abnormal laboratory findings which were organized by organ and apparatus. Family doctors and rheumatologists with an interest in autoimmune systemic diseases were selected and formed mixed groups of two that then elaborated algorithms for diagnostic guidelines and referral. The algorithms were then reviewed, homogenized and adapted to the algorithm format and application for cell phone (apps) download. The result is the current Referral document of systemic autoimmune diseases for the family doctor in paper format and app (download). It contains easy-to-use algorithms using data from anamnesis, physical examination and laboratory results usually available to primary care, that help diagnose and refer patients to rheumatology or other specialties if needed

Outcomes of patient self-referral for the diagnosis of several rare inherited kidney diseases.

PURPOSE: To evaluate self-referral from the Internet for genetic diagnosis of several rare inherited kidney diseases. METHODS: Retrospective study from 1996 to 2017 analyzing data from an academic referral center specializing in autosomal dominant tubulointerstitial kidney disease (ADTKD). Individuals were referred by academic health-care providers (HCPs) nonacademic HCPs, or directly by patients/families. RESULTS: Over 21 years, there were 665 referrals, with 176 (27%) directly from families, 269 (40%) from academic HCPs, and 220 (33%) from nonacademic HCPs. Forty-two (24%) direct family referrals had positive genetic testing versus 73 (27%) families from academic HCPs and 55 (25%) from nonacademic HCPs (P = 0.72). Ninety-nine percent of direct family contacts were white and resided in zip code locations with a mean median income of $77,316 ± 34,014 versus US median income $49,445. CONCLUSION: Undiagnosed families with Internet access bypassed their physicians and established direct contact with an academic center specializing in inherited kidney disease to achieve a diagnosis. Twenty-five percent of all families diagnosed with ADTKD were the result of direct family referral and would otherwise have been undiagnosed. If patients suspect a rare disorder that is undiagnosed by their physicians, actively pursuing self-diagnosis using the Internet can be successful. Centers interested in rare disorders should consider improving direct access to families.

Encounter Decision Aids Can Prompt Breast Cancer Surgery Cost Discussions: Analysis of Recorded Consultations.

Background. Patients frequently worry about care costs, but clinicians seldom address the topic. Cost information is not typically included in patient decision aids (DAs). We examined whether including cost information in an encounter DA, with clinician training, influenced cost conversations. Method. As part of a larger trial, 14 surgeons from 4 cancer centers were randomized to 1 of 3 interventions: (1) Picture Option Grid DA that included a prompt to discuss relative treatment costs, hereafter called "cost prompt group"; (2) a text-only Option Grid DA that did not include cost information; (3) usual care. Groups 2 and 3 hereafter are referred to as "non-cost prompt groups." Adult (18+) female patients, with stages I-IIIA breast cancer, eligible for both breast-conserving surgery and mastectomy were included. We gave surgeons feedback about adherence to the study protocol at 3, 6, and 12-months. We adapted a checklist to code the content of the audio-recorded clinical encounters. Results. 424/622 (68%) patients consented; 311 (73%) were eligible and successfully recorded (143 in the cost prompt group, 168 in the non-cost prompt groups). Costs were discussed in 132/311 (42.4%) encounters, and occurred more often in the cost prompt versus non-cost prompt groups (66.7% versus 33.3%; p<.001). Surgeons initiated the cost discussion in 86.4% of encounters in the cost prompt group vs. 34.1% in the non-cost prompt groups (p<0.001). In the non-cost prompt groups, insurance or employment questions led patients to ask about costs. Cost discussions lasted about 34 seconds when present and had sparse comparative details. Conclusions. Encounter DAs containing cost information trigger cost discussions. Additional support should help clinicians improve the quality of cost discussions and address financial distress.

General practitioners' use of ICPC diagnoses and their correspondence with patient record notes. / Allmennlegers bruk av ICPC-diagnoser og samsvar med journalnotatene.

BACKGROUND: The quality of the general practitioners' setting of diagnoses using codes from the International Classification for Primary Care (ICPC) is important, because these codes are used for purposes of quality development, research and public health statistics. It is uncertain, however, to what extent these diagnoses present a correct picture of the content of and reasons for the consultations and the prevalence of illness in the population. The objective of this study was to identify the extent to which the general practitioners' use of diagnostic codes correlates with the content of the patient record notes. MATERIAL AND METHOD: A total of 23 general practitioners from five different medical centres in Agder county participated in the study. The patient record notes from all patient contacts over two working days in 2013 were reviewed by two experienced general practitioners who assessed the degree of correspondence between the content of the patient record notes and the concomitant ICPC diagnostic codes. RESULTS: A total of 1 819 patient contact were assessed, and for 1 591 of these (87.5 %) it was possible to assess the correspondence between the patient record notes and the diagnosis. We found good correspondence for 693 (85.3 %) consultations and 321 (69.9 %) simple contacts with issuance of a prescription. For simple contacts with no issuance of a prescription there was good correspondence for 213 (83.9 %), although 144 of a total of 398 (36.2 %) could not be assessed because the patient record notes were absent, too brief or imprecise. INTERPRETATION: The diagnoses made during consultations corresponded well with the patient record notes examined in this study. The results may indicate that caution should be exercised in including simple contacts in the data on diagnoses in public statistics. The findings should be followed up in larger-scale and more representative national studies.

Cardiopulmonary Exercise Testing, Impedance Cardiography, and Reclassification of Risk in Patients Referred for Heart Failure Evaluation.

BACKGROUND: An impaired cardiac output response to exercise is a hallmark of chronic heart failure (HF). We determined the extent to which impedance cardiography (ICG) during exercise in combination with cardiopulmonary exercise test (CPX) responses reclassified risk for adverse events in patients with HF. METHODS AND RESULTS: CPX and ICG were performed in 1236 consecutive patients (48±15 years) evaluated for HF. Clinical, ICG and CPX variables were acquired at baseline and subjects were followed for the composite outcome of cardiac-related death, hospitalization for worsening HF, cardiac transplantation, and left ventricular assist device implantation. Cox proportional hazards analyses including clinical, noninvasive hemodynamic, and CPX variables were performed to determine their association with the composite endpoint. Net reclassification improvement (NRI) was calculated to quantify the impact of adding hemodynamic responses to a model including established CPX risk markers on reclassifying risk. There were 422 events. Among CPX variables, peak VO2 and indices of ventilatory inefficiency (VE/VCO2 slope, oxygen uptake efficiency slope) were significant predictors of risk for adverse events. Among hemodynamic variables, change in cardiac index, peak cardiac time interval, and peak left cardiac work index were the strongest predictors of risk. Having 5 impaired CPX and ICG responses to exercise yielded a sevenfold higher risk for adverse events compared with having no abnormal responses. Combining ICG responses to CPX resulted in NRIs ranging between 0.34 and 0.89, attributable to better reclassification of events. CONCLUSION: Cardiac hemodynamics determined by ICG complement established CPX measures in reclassifying risk among patients with HF.

Does changed referral options affect the use of MRI for patients with low back pain? Evidence from a natural experiment using nationwide data.

OBJECTIVES: This study reports lumbar MRI referral patterns in the Region of Southern Denmark (RSD) and investigates the hypothesis that we will see an increase in imaging rates (MRI rates) following new referral options to lumbar MRI in the RSD in comparison with the other regions in Denmark from 2010 to 2013. DESIGN: A difference-in-difference (DD) analysis, using general practitioners (GPs) in other regions as control, was used to test if the new referral options had an effect on the MRI rates. SETTING: In 2010, RSD introduced organisational changes affecting the referral options for lumbar MRI. First, the possibility for direct referral to lumbar MRI was introduced GPs, and second, the region gathered all local spine departments into one specialist hospital called the Spine Centre. PARTICIPANTS: We retrieved all lumbar MRIs performed on patients aged 18+ performed on Danish hospitals from 2008 to 2013 using the registries from Statistics Denmark. We use sociodemographic information from all Danish citizens aged 18+ aggregated to GP level. Primary and secondary outcome measures: lumbar MRI scans per 1000 capita enlisted with a GP (MRI rates) were calculated based on GPs patient list. Four referral types were made to describe changes in referral patterns. RESULTS: In total 183 389 patients received 240 760 lumbar MRIs in the period. The use of the direct referral option by GPs in the RSD increased by 115% in the period from 2010 to 2013 and accounted for 34% of all referrals (n=6545) in 2013. MRI rates were significantly higher in RSD following the organisational changes (DD 1.389(0.925-1.852) lumbar MRI per 1.000 enlisted with a GP). CONCLUSIONS: Introduction of organisational changes in RSD as direct referral to lumbar MRI from GPs and chiropractors as well as establishing a Spine Centre increase the lumbar MRI rate in comparison with other regions in Denmark.

Emergency Department Discharge Outcome and Psychiatric Consultation in North African Patients.

Studies in Europe have found that immigrants, compared to the local population, are more likely to seek out medical care in Emergency Departments (EDs). In addition, studies show that immigrants utilize medical services provided by EDs for less acute issues. Despite these observed differences, little is known about the characteristics of ED use by North African (NA) immigrants. The main objective of this study was to examine whether there were differences in ED discharge outcomes and psychiatric referrals between NA immigrants and Swiss nationals. A retrospective analysis was conducted using patient records from NA and Swiss adults who were admitted to the ED of the University Hospital in Bern (Switzerland) from 2013⁻2016. Measures included demographic information as well as data on types of admission. Outcome variables included discharge type and psychiatric referral. A total of 77,619 patients generated 116,859 consultations to the ED, of which 1.1 per cent (n = 1338) were consultations by NA patients. Compared to Swiss national patients, NA patients were younger, with a median age of 38.0 (IQR 28⁻51 years vs. 52.0 (IQR 32⁻52) for Swiss and predominantly male (74.4% vs. 55.6% in the Swiss). NA patient admission type was more likely to be "walk-in" or legal admission (7.5% vs 0.8 in Swiss,). Logistic regressions indicated that NA patients had 1.2 times higher odds (95% CI 1.07⁻1.40, p < 0.003) of receiving ambulatory care. An effect modification by age group and sex was observed for the primary outcome "seen by a psychiatrist", especially for men in the 16⁻25 years age group, whereby male NA patients had 3.45 times higher odds (95% CI: 2.22⁻5.38) of having being seen by a psychiatrist. In conclusion differences were observed between NA and Swiss national patients in ED consultations referrals and outcomes, in which NA had more ambulatory discharges and NA males, especially young, were more likely to have been seen by psychiatrist. Future studies would benefit from identifying those factors underlying these differences in ED utilization.

Risk classification of patients referred to secondary care for low back pain.

BACKGROUND: Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. METHODS: An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen's Kappa coefficient, Pearson's r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. RESULTS: A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. CONCLUSION: The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production.

OBJECTIVES: To examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved. DESIGN: Mixed-method evaluation of a primary care e-consultation system. SETTING: Primary care practices in South West England. METHODS: Qualitative interviews with 23 practice staff in six practices. Patient survey data for 756 e-consultations from 36 practices, with free-text survey comments from 512 patients, were analysed thematically. Anonymised patients' records were abstracted for 485 e-consultations from eight practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and the usage of the e-consultation system were informed by: (1) normalisation process theory, (2) a framework that illustrates how e-consultations were co-produced and (3) patients' and staff touchpoints. RESULTS: We found different expectations between patients and staff on how to use e-consultations 'appropriately'. While some patients used the system to try and save time for themselves and their general practitioners (GPs), some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation. CONCLUSIONS: Where both patients and staff interact with technology, it is in effect 'co-implemented'. How patients used e-consultations impacted on practice staff's experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.

Enhanced Versus Basic Referral for Intimate Partner Violence in an Urban Emergency Department Setting.

BACKGROUND: Victims of intimate partner violence (IPV) frequently do not disclose abuse to medical providers. Therefore, research has examined the most effective screening and referral methods to help identify victims of abuse and connect them to needed resources. OBJECTIVES: To determine the efficacy of referrals intended to connect IPV victims with behavioral health resources, while taking into consideration demographic and mental health variables. METHODS: We examined a convenience sample of medically stable individuals in an emergency department setting. Participants were given the Mini-International Neuropsychiatric Interview and Partner Violence Screen measures to assess mental health and IPV victimization. Individuals that screened positive were randomized to a basic or enhanced referral and given a follow-up interview to determine referral success. Referrals were considered successful if an individual scheduled an appointment with provided behavioral health resources within the follow-up interval. RESULTS: Two-hundred and one individuals were enrolled. Forty-one (20.4%) participants screened positive for IPV victimization. Male and female participants in the enhanced referral group were more likely to have a successful referral than those in the basic referral group, with a large effect size such that 72.7% of participants in the enhanced referral and 15.7% of participants in the basic referral group contacted referral resources. Both referral type and marital status significantly predicted referral success. CONCLUSION: Comorbidity with mental health concerns measured as high within those that screened positive for IPV victimization. The enhanced referral showed to be an effective way to encourage participants to contact behavioral health resources.

Validation of the V66.7 Code for Palliative Care Consultation in a Single Academic Medical Center.

BACKGROUND: Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown. OBJECTIVE: To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation. DESIGN: Retrospective cohort study. SETTING/SUBJECTS: All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015. MEASUREMENTS: Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record. RESULTS: Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846 (1.8%) had usage of the V66.7 code. Sensitivity and specificity for the V66.7 code were 49.9% and 99.1%, respectively. Sensitivity was considerably higher for certain subgroups, such as patients with dementia (76.3%) and metastatic cancer (66.3%); addition of age restrictions further improved sensitivity while maintaining high specificity. Specificity was substantially lower for patients who died during hospitalization (sensitivity 53.9%, specificity 75.1%). CONCLUSIONS: In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation. Appropriate use of this code for this purpose should take these characteristics into consideration.

The Foundation in Evidence of Medical and Dental Telephone Consultations.

BACKGROUND: Patients can only make well-informed decisions if the information they are given by health professionals is based on scientific evidence. In this study, we assessed the foundation in evidence of free, publicly available telephone consultations in Germany. METHODS: From March 2013 to January 2014, four hidden clients seeking information asked standardized questions about three medical topics (screening for colorectal cancer, for glaucoma, and for trisomy 21) and three dental ones (the sealing of dental fissures, professional dental cleaning, and mercury detoxification). Depending on the topic, the questions addressed such issues as the risk of disease and the purpose, content, validity, benefits, and risks of potential diagnostic and therapeutic measures. All identifiable telephone consultation services that provided counselling on the above topics were included in the study (23 government-sponsored institutions, 31 institutions independently run by physicians, 521 institutions under religious auspices, 25 dental counselling services). RESULTS: Of the 599 telephone consultation services that were identified, 567 were contacted; 404 did not offer any relevant counselling. A total of 293 conversations were held with the remaining 163 consultation services. Six of these conversations fully met predefined criteria for evidence-based counselling. The percentage of appropriate answers to the key questions on each topic was 5% for colorectal cancer screening (7/140), 23.8% for glaucoma screening (25/105), 33.9% for trisomy 21 screening (121/357), 27.5% for the sealing of dental fissures (28/102), 16.2% for professional dental cleaning (19/117), and 12.9% for mercury detoxification (12/93). The percentage of appropriate answers also varied depending on the type of institution: 26.8% for government-sponsored institutions (67/250), 4.5% for institutions independently run by physicians (4/88), and 31.1% for institutions under religious auspices (82/264). CONCLUSION: The medical and dental counselling now offered over the telephone by the types of institutions included in this study does not satisfy the criteria for evidence-based health information.

Typologies in GPs' referral practice.

BACKGROUND: GPs' individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs' referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. METHODS: Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP's age, gender, specialty in family medicine and location as independent variables. RESULTS: Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients' pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. CONCLUSIONS: Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence.