Factors that Affect Patient Wait Times at a Free Clinic.

Free clinics may present long wait times. A retrospective chart review was conducted at a free clinic to understand contributing factors. Three wait times (total visit time, lobby wait time, and triage time) were analyzed across 349 patients. Variables included in the models were the total number of patients, providers, and volunteers; interpreter services; social work involvement; medical complexity; new vs. returning patient; scheduled vs. walk-in appointment; transportation provision; medical volunteer training level; and on-site medications and labs. Data analysis with multiple regressions was conducted. Factors that significantly affected wait times included the level of medical complexity (p<.001), medical volunteer training levels (p<.001), in-house labs (p<.001), in-house medications (p=.04), and new patients (p=.01). An intervention involving time benchmarks at the beginning of clinics reduced first-wave lobby wait times (p<.001). Future interventions addressing these factors may reduce wait times at other clinics.

School-Based Services May Eliminate Substance Treatment Disparities: Results From a Nonrandomized Program Evaluation.

BACKGROUND: There are known health disparities in adolescent substance treatment access and engagement. The purpose of this project is to compare outcomes from school- and clinic-based substance treatment and to evaluate if providing school-based substance treatment reduces disparities in treatment access and engagement. METHOD: This quality improvement retrospective chart review compares baseline and outcome data for adolescents accessing school-based (n = 531) and clinic-based (n = 523) substance treatment in a natural quasi-experimental study with nonequivalent control group design. Baseline demographic and clinical measures include age, sex, ethnicity, race, and clinical diagnoses. Outcome measures include the number of sessions completed, proportion reaching a week of self-reported abstinence, and proportion providing a negative urine drug screen. RESULTS: Compared to the clinic-based sample, the school-based sample includes more female (47.65% vs 26.77%) and Hispanic/Latinx (59.89% vs 46.46%) adolescents. The school-based group has a similar proportion reaching a negative urine drug screen (31.84% vs 28.83%, p = .5259) or a week of abstinence (43.15% vs 41.03%, p = .6718) as the clinic-based sample. There are significant differences in total session completion over a period of 16 weeks between school-based and clinic-based adolescents. In multivariable analyses, there was a significant interaction effect of race/ethnicity by location on the number of sessions completed. CONCLUSION: Providing school-based substance treatment increases access to care and treatment engagement for female, African American, and Hispanic/Latinx adolescents without diminishing outcomes.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings.

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Progression of chronic kidney disease among black patients attending a tertiary hospital in Johannesburg, South Africa.

BACKGROUND: Chronic kidney disease (CKD) is a major public health issue worldwide and is an important contributor to the overall non-communicable disease burden. Chronic kidney disease is usually asymptomatic, and insidiously and silently progresses to advanced stages in resource limited settings. METHODOLOGY: A prospective longitudinal study was carried out on black patients with CKD attending the kidney outpatient clinic at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa, between September 2019 to March 2022. Demographic and clinical data were extracted from the ongoing continuous clinic records, as well as measurements of vital signs and interviews at baseline and at follow up. Patients provided urine and blood samples for laboratory investigations as standard of care at study entry (0) and at 24 months, and were followed up prospectively for two (2) years. Data were descriptively and inferentially entered into REDcap and analysed using STATA version 17, and multivariable logistic regression analysis was used to identify predictors of CKD progression. RESULTS: A total of 312 patients were enrolled into the study, 297 (95.2%) patients completed the study, 10 (3.2%) patients were lost to follow and 5 (1.6%) patients died during the study period. The prevalence of CKD progression was 49.5%, while that of CKD remission was 33% and CKD regression was 17.5%. For patients with CKD progression the median age at baseline was 58 (46-67) years, the median eGFR was 37 (32-51) mL/min/1.73 m2, median urine protein creatinine ratio (uPCR) was 0.038 (0.016-0.82) g/mmol and the median haemoglobin (Hb) was 13.1 (11.7-14.4) g/dl; 95.2% had hypertension, 40.1% patients had diabetes mellitus and 39.5% had both hypertension and diabetes mellitus. Almost half (48.3%) of patients with CKD progression had severely increased proteinuria and 45.6% had anaemia. Variables associated with higher odds for CKD progression after multivariable logistic regression analysis were severely increased proteinuria (OR 32.3, 95% CI 2.8-368.6, P = 0.005), moderately increased proteinuria (OR 23.3, 95% CI 2.6-230.1, P = 0.007), hypocalcaemia (OR 3.8, 95% CI 1.0-14.8, P = 0.047), hyponatraemia (OR 4.5, 95% CI 0.8-23.6, P = 0.042), anaemia (OR 2.1, 95% CI 1.0-4.3, P = 0.048), diabetes mellitus (OR 1.8, 95% CI 0.9-3.6, P = 0.047), elevated HbA1c (OR 1.8, 95% CI 1.2-2.8, P = 0.007) and current smoking (OR 2.8, 95% CI 0.9-8.6, P = 0.049). CONCLUSION: Our study identified a higher prevalence of CKD progression in a prospective longitudinal study of black patients with CKD compared with literature reports. CKD Progression was associated with proteinuria, diabetes mellitus, elevated HbA1c, anaemia, hypocalcaemia, hyponatraemia and current smoking in a cohort of black patients with CKD who had controlled hypertension and diabetes mellitus at baseline.

Utilization of Small Dense Low-Density Lipoprotein Cholesterol Testing in Korean Patients Visiting Local Clinics and Hospitals.

Small dense low-density cholesterol (sdLDL) has been the focus of studies due to its potential as an independent risk factor for atherosclerotic cardiovascular diseases. We aimed to investigate the utilization of sdLDL testing by LDL particle size analysis and the prevalence of an sdLDL predominant phenotype in Korean adult patients by visiting local clinics and hospitals. Among 9222 Korean adults (4577 men and 4645 women) with a median age of 62.8 years (interquartile range, IQR 54.5 to 71.8 years) undergoing lipid profile testing using LDL particle size analysis, the prevalence of hypercholesterolemia (total cholesterol ≥ 240 mg/dL), hypo HDL cholesterolemia (<40 mg/dL), and hyper LDL cholesterolemia (≥160 mg/dL) was 7.8%, 12.9%, and 0.5%, respectively. The overall prevalence of the sdLDL predominant non-A phenotype of LDL was 46.8% of study subjects. Approximately 32.8% of the study subjects possessed lipid test results that did not exhibit increased risk except for sdLDL (only the sdLDL predominant non-A phenotype as a risk factor). In Korea, sdLDL testing was utilized in patients whose LDL cholesterol level was not increased. Future studies to clarify the clinical significance of this test in the Korean population are needed.

Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US.

Importance: Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown. Objective: To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis. Design, Setting, and Participants: This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019). Exposures: Time-updated profit status of dialysis facilities. Main Outcomes and Measures: Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities. Results: A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74). Conclusions and Relevance: Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Characterizing 30-Day Postoperative Acute Care Visits: A National Surgical Quality Improvement Program Collaborative Analysis.

INTRODUCTION: Many postoperative acute care visits (PACVs) are likely more appropriately addressed in lower acuity settings; however, the frequency and nature of PACVs are not currently tracked by the National Surgical Quality Improvement Program (NSQIP), and the overall burden to emergency departments and urgent care centers is unknown. METHODS: NSQIP collaborative data were augmented to prospectively capture 30-d PACVs for 1 y starting October 2018 across all NSQIP specialties, including visit reason and disposition. Data were analyzed using binomial logistic regression. RESULTS: A total of 9933 patients were identified; 12.0% (n = 1193) presented to an acute care setting over 1413 visits, most commonly for surgical pain (15.4%) in the absence of an identified complication. Visits most commonly resulted in discharge (n = 817, 68.5%) or admission (n = 343, 24.3%). Variables independently associated with visits resulting in discharge included age (odds ratio [OR] 0.99 per year, P < 0.001), increasing comorbidities (1-2 [OR 1.55, P < 0.001]; 3-4 [OR 2.51, P < 0.001]; 5+ [OR 2.79 P < 0.001]), operative duration (OR 1.08 per hour, P = 0.001), and nonelective (OR 1.20, P = 0.01) or urologic (OR 1.46, P = 0.01) procedures. CONCLUSIONS: PACVs are an overlooked burden on emergency medicine providers and healthcare systems; most do not require admission and could be potentially triaged outside of the acute care setting with improved perioperative care infrastructure. Younger patients, those with multiple comorbidities, and those undergoing nonelective procedures deserve special attention when designing initiatives to address postoperative acute care utilization. Data regarding PACVs can be routinely collected with minor modifications to current NSQIP workflows.

"I just have to hope that this abortion should go well": Perceptions, fears, and experiences of abortion clients in Nigeria.

This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients' own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.

Visual aids in ambulatory clinical practice: Experiences, perceptions and needs of patients and healthcare professionals.

This study aims to explore how visual aids (VA) are used in ambulatory medical practice. Our research group (two doctors, one graphic designer and one sociologist) have led a qualitative study based on Focus Groups. A semi-structured guide and examples of VA were used to stimulate discussions. Participants were healthcare professionals (HP) working in ambulatory practice in Geneva and French-speaking outpatients. After inductive thematic analysis, the coding process was analyzed and modified to eventually reach consensus. Six focus groups gathered twenty-one HP and fifteen patients. Our study underlines the variety of purposes of use of VA and the different contexts of use allowing the distinction between "stand-alone" VA used out of consultation by patients alone and "interactive" VA used during a consultation enriched by the interaction between HP and patients. HP described that VA can take the form of useful tools for education and communication during consultation. They have questioned the quality of available VA and complained about restricted access to them. Patients expressed concern about the impact of VA on the interaction with HP. Participants agreed on the beneficial role of VA to supplement verbal explanation and text. Our study emphasizes the need to classify available VA, guarantee their quality, facilitate their access and deliver pertinent instructions for use.

Fracture Prevention Clinic Targeting Patients with Fragility Fracture of the Distal Radius: A Pilot Study.

BACKGROUND: Identifying and treating patients with fragility fractures may be effective in prevention of subsequent fractures because a first fragility fracture often predicts a second fracture. OBJECTIVES: To evaluate a multidisciplinary anti-osteoporotic clinic for patients with prior distal radius fragility fractures (DRFF). To assess whether addressing this early fracture may prevent a second fracture. METHODS: A retrospective case-control study was performed. Cases included patients treated surgically for DRFF who were assessed at a tertiary, multidisciplinary, fracture-prevention clinic. Controls were a series of similarly treated patients who did not attend the clinic. The primary outcome measure was a second fracture. RESULTS: Average follow-up was 42 months for the treated group and 85 months for the untreated group. The treated group received more treatment for osteoporosis than controls; however, despite one new fracture in the treated group and six new fractures in the control group, there was no significant difference in fracture occurrence. CONCLUSIONS: This pilot study supports the effectiveness of our multidisciplinary anti-osteoporotic clinic in treating osteoporosis but not in reducing subsequent fractures. Further study with larger cohorts and longer follow-up is needed to improve our ability to implement effective prevention of fragility fractures.

Leptin promoter methylation in female patients with painful multisomatoform disorder and chronic widespread pain.

BACKGROUND: Different functional somatic syndromes (FSS), fibromyalgia (FMS) and other unexplained painful conditions share many common clinical traits and are characterized by troubling and functionally disabling somatic symptoms. Chronic pain is most frequently reported and at the center of patients' level of disease burden. The construct of multisomatoform disorder (MSD) allows to subsume severely impaired patients suffering from FSS, FMS and other unexplained painful conditions to be examined for common underlying processes. Altered leptin levels and a pathological response of the HPA-axis as a result of chronic stress and childhood trauma have been suggested as one of the driving factors of disease development and severity. Previous studies have demonstrated that methylation of the leptin promoter can play a regulatory role in addiction. In this study, we hypothesized that methylation of the leptin promoter is influenced by the degree of childhood traumatization and differs between patients with MSD and controls. A cohort of 151 patients with MSD and 149 matched healthy volunteers were evaluated using clinical and psychometric assessment while methylation level analysis of the leptin promoter was performed using DNA isolated from whole blood. RESULTS: In female controls, we found CpG C-167 to be negatively correlated with leptin levels, whereas in female patients CpG C-289, C-255, C-193, C-167 and methylation cluster (C-291 to C-167) at putative bindings sites for transcription factors Sp1 and c/EBPalpha were negatively correlated with leptin levels. Methylation levels were significantly lower in female patients CpG C-289 compared with controls. When looking at female patients with chronic widespread pain methylation levels were significantly lower at CpG C-289, C-255 and methylation cluster (C-291 to C-167). CONCLUSION: Our findings support the hypothesis that epigenetic regulation of leptin plays a role in the regulation of leptin levels in patients with MSD. This effect is more pronounced in patients with chronic widespread pain.

Functional dyspepsia leads to more healthcare utilization in secondary care compared with other functional gastrointestinal disorders.

OBJECTIVE: Functional gastrointestinal disorders (FGIDs) are known to have a significant impact on patients' quality of life and lead to a greater healthcare burden. In this study we aimed to investigate whether this healthcare burden differs among various types of FGIDs in secondary care. METHODS: A retrospective study of consecutive adults with luminal gastrointestinal (GI) diseases in a secondary healthcare gastroenterology clinic was conducted. The frequency of FGIDs and differences in healthcare utilization among different types of FGIDs were explored. RESULTS: Among 1206 patients with luminal GI disease, 442 (36.7%) had FGIDs. FGIDs patients were older (67 y vs 62 y, P < 0.001) with a higher proportion of women (61.8% vs 50.4%, P < 0.001) than those without FGIDs. Functional dyspepsia (FD) was the most common FGIDs (36.9%), followed by irritable bowel syndrome (IBS) (30.3%). A high healthcare burden (defined as over one GI endoscopy or imaging examination over 5 years, or one or more unscheduled visit to general practitioner or emergency department or hospitalization annually) was observed among 53.8% of the FGIDs patients. FD was associated with a high healthcare burden (high vs low burden: 43.7% vs 28.9%, P = 0.001) while IBS was associated with lower healthcare burden (high vs low burden: 25.2% vs 36.3%, P = 0.012). On multivariate analysis, only FD was significantly associated with high healthcare burden (adjusted odds ratio 1.996, 95% confidence interval 1.117-3.567, P = 0.020). CONCLUSION: Compared with other FGIDs, FD was the most common condition in secondary care, and it was associated with the greatest healthcare burden.

COVID-19 Testing Among US Children, Parental Preferences for Testing Venues, and Acceptability of School-Based Testing.

OBJECTIVES: Testing remains critical for identifying pediatric cases of COVID-19 and as a public health intervention to contain infections. We surveyed US parents to measure the proportion of children tested for COVID-19 since the start of the pandemic, preferred testing venues for children, and acceptability of school-based COVID-19 testing. METHODS: We conducted an online survey of 2074 US parents of children aged ≤12 years in March 2021. We applied survey weights to generate national estimates, and we used Rao-Scott adjusted Pearson χ2 tests to compare incidence by selected sociodemographic characteristics. We used Poisson regression models with robust SEs to estimate adjusted risk ratios (aRRs) of pediatric testing. RESULTS: Among US parents, 35.9% reported their youngest child had ever been tested for COVID-19. Parents who were female versus male (aRR = 0.69; 95% CI, 0.60-0.79), Asian versus non-Hispanic White (aRR = 0.58; 95% CI, 0.39-0.87), and from the Midwest versus the Northeast (aRR = 0.76; 95% CI, 0.63-0.91) were less likely to report testing of a child. Children who had health insurance versus no health insurance (aRR = 1.38; 95% CI, 1.05-1.81), were attending in-person school/daycare versus not attending (aRR = 1.67; 95% CI, 1.43-1.95), and were from households with annual household income ≥$100 000 versus income <$50 000-$99 999 (aRR = 1.19; 95% CI, 1.02-1.40) were more likely to have tested for COVID-19. Half of parents (52.7%) reported the pediatrician's office as the most preferred testing venue, and 50.6% said they would allow their youngest child to be tested for COVID-19 at school/daycare if required. CONCLUSIONS: Greater efforts are needed to ensure access to COVID-19 testing for US children, including those without health insurance.

Efficacy of Inhaled Ciclesonide for Outpatient Treatment of Adolescents and Adults With Symptomatic COVID-19: A Randomized Clinical Trial.

Importance: Systemic corticosteroids are commonly used in treating severe COVID-19. However, the role of inhaled corticosteroids in the treatment of patients with mild to moderate disease is less clear. Objective: To determine the efficacy of the inhaled steroid ciclesonide in reducing the time to alleviation of all COVID-19-related symptoms among nonhospitalized participants with symptomatic COVID-19 infection. Design, Setting, and Participants: This phase 3, multicenter, double-blind, randomized clinical trial was conducted at 10 centers throughout the US and assessed the safety and efficacy of a ciclesonide metered-dose inhaler (MDI) for treating nonhospitalized participants with symptomatic COVID-19 infection who were screened from June 11, 2020, to November 3, 2020. Interventions: Participants were randomly assigned to receive ciclesonide MDI, 160 µg per actuation, for a total of 2 actuations twice a day (total daily dose, 640 µg) or placebo for 30 days. Main Outcomes and Measures: The primary end point was time to alleviation of all COVID-19-related symptoms (cough, dyspnea, chills, feeling feverish, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell) by day 30. Secondary end points included subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19. Results: A total of 413 participants were screened and 400 (96.9%) were enrolled and randomized (197 [49.3%] in the ciclesonide arm and 203 [50.7%] in the placebo arm; mean [SD] age, 43.3 [16.9] years; 221 [55.3%] female; 2 [0.5%] Asian, 47 [11.8%] Black or African American, 3 [0.8%] Native Hawaiian or other Pacific Islander, 345 [86.3%] White, and 1 multiracial individuals [0.3%]; 172 Hispanic or Latino individuals [43.0%]). The median time to alleviation of all COVID-19-related symptoms was 19.0 days (95% CI, 14.0-21.0) in the ciclesonide arm and 19.0 days (95% CI, 16.0-23.0) in the placebo arm. There was no difference in resolution of all symptoms by day 30 (odds ratio, 1.28; 95% CI, 0.84-1.97). Participants who were treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons related to COVID-19 (odds ratio, 0.18; 95% CI, 0.04-0.85). No participants died during the study. Conclusions and Relevance: The results of this randomized clinical trial demonstrated that ciclesonide did not achieve the primary efficacy end point of reduced time to alleviation of all COVID-19-related symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT04377711.

Longitudinal progression of diabetes mellitus in Wolfram syndrome: The Washington University Wolfram Research Clinic experience.

OBJECTIVE: (1) Describe the progression of diabetes mellitus over time in an observational study of Wolfram syndrome, a rare, genetic, neurodegenerative disorder, which often includes diabetes mellitus and is typically diagnosed during childhood or adolescence. (2) Determine whether C-peptide could be used as a marker of diabetes progression in interventional trials for Wolfram syndrome. METHODS: N = 44 (25F/19M) participants with genetically confirmed Wolfram syndrome attended the Washington University Wolfram Research Clinic annually from 2010 to 2019. Medical history, physical examinations, blood sampling, and questionnaires were used to collect data about diabetes mellitus and other components of Wolfram syndrome. Beta-cell function was assessed by determination of C-peptide during a mixed meal tolerance test. Random coefficients models evaluated the rate of progression of C-peptide over time, and power analyses were used to estimate the number of subjects needed to detect a change in C-peptide decline during an intervention trial. RESULTS: 93.2% of patients had diabetes mellitus. Mean HbA1c across all study visits was 7.9%. C-peptide significantly decreased with increasing duration of diabetes mellitus (p < 0.0001); an optimal break point in C-peptide decline was identified to occur between 0.1 and 2.3 years after diabetes mellitus diagnosis. Twenty patients per group (active vs. control) were estimated to be needed to detect a 60% slowing of C-peptide decline during the first 2.3 years following diabetes diagnosis. CONCLUSION: C-peptide declines over time in Wolfram syndrome and could potentially be used as a marker of diabetes progression in interventional studies for Wolfram syndrome, especially within the first 2 years after diabetes diagnosis.

Characteristics of Children Diagnosed With SARS-CoV-2 in the Ambulatory Setting.

The objective of this study was to characterize the clinical presentation and outcomes of children and adolescents testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the ambulatory setting. We found that about 8% of children tested positive for SARS-CoV-2, with the large majority being symptomatic (80%). The average age of our population was 12.5 years, and females and males were affected equally. However, African American patients (62%) were substantially more likely to test positive compared with other races. Children in this study tended to have a mild course, mostly presenting with respiratory symptoms, and very few required hospitalization. As the epidemiology of the pandemic evolves, it will be important to monitor the effects that changing variants have on infected children and the impact that vaccination programs have on mitigating infection risk.

Are We Reaching Everyone? A Cross-Sectional Study of Telehealth Inequity in the COVID-19 Pandemic in an Urban Academic Pediatric Primary Care Clinic.

The COVID-19 (coronavirus disease 2019) pandemic brought rapid expansion of pediatric telehealth to maintain patient access to care while decreasing COVID-19 community spread. We designed a retrospective, serial, cross-sectional study to investigate if telehealth implementation at an academic pediatric practice led to disparities in health care access. Significant differences were found in pre-COVID-19 versus during COVID-19 patient demographics. Patients seen during COVID-19 were more likely to be younger, White/Caucasian or Asian, English speaking, and have private insurance. They were less likely to be Black/African American or Latinx and request interpreters. Age was the only significant difference in patient demographics between in-person and telehealth visits during COVID-19. A multivariate regression showed older age as a significant positive predictor of having a video visit and public insurance as a significant negative predictor. Our study demonstrates telehealth disparities based on insurance existed at our clinic as did inequities in who was seen before versus during COVID-19.

Paediatric NHS 111 Clinical Assessment Services pilot: an observational study.

OBJECTIVE: To determine the feasibility and impact of having paediatric clinicians working in the Clinical Assessment Services (CAS) within NHS 111, a national telephone advice service. DESIGN: Observational study. SETTING: Six NHS 111 providers across England with CAS where volunteer paediatric clinicians (doctors and advanced nurse practitioners (ANPs)) worked between May and December 2020. A data reporting framework was used to compare the outcomes of calls taken by paediatric vs non-paediatric clinicians. PATIENTS: Under 16-year-olds prompting calls to NHS 111 over the study period. MAIN OUTCOME MEASURES: The disposition (final outcome of calls) taken by paediatric versus non-paediatric clinicians, paediatric clinicians' and patient experience. RESULTS: 70 paediatric clinicians (66 doctors and 4 ANPs) worked flexible shifts in six NHS 111 providers' CAS over the study period: 2535 calls for under 16-year-olds were taken by paediatric clinicians and 137 008 by non-paediatric clinicians. Overall, disposition rates differed significantly between the calls taken by paediatric versus (vs) non-paediatric clinicians: 69% vs 43% were advised on self-care only, 13% vs 18% to attend emergency departments (EDs), 13% vs 29% to attend primary care, 1% vs 4% to receive an urgent ambulance call out and 4% vs 6% referred to another health service, respectively. When compared with recent (all age) national whole data sets, the feedback from calls taken by paediatricians noted a greater proportion of patients/carers reporting that their problem was fully resolved (92% vs 27%). CONCLUSIONS: Introducing paediatric specialists into NHS 111 CAS is likely to increase self-care dispositions, and reduce onward referrals to primary care, ED and ambulances. Future work will evaluate the impact of a national paediatric clinical assessment service to which specific case types are streamed.

Factors associated with testing positive for syphilis among MSM who present as sexual contacts of syphilis from a clinic-based population.

OBJECTIVES: There has been a significant increase in syphilis in men who have sex with men (MSM) in the UK over the past 20 years. Partner notification strategies have increased the number of MSM attending STI clinics as sexual contacts of syphilis. Current guidelines suggest testing and consideration of presumptive antimicrobial treatment. Syphilis treatment with benzathine penicillin requires clinic resources, is painful and is associated with complications. It is important we consider strategies to rationalise presumptive antimicrobial use and promote antimicrobial stewardship. METHODS: We aimed to determine if there are any factors associated with having syphilis among MSM attending as sexual contacts of syphilis in a cross-sectional study. We examined the clinical records of MSM attending as sexual contacts of syphilis from January to December 2019. RESULTS: Of the 6613 MSM who attended for STI testing, 142 of 6613 (2.1%) presented as sexual contacts of syphilis. The median age was 40 years (IQR=31-51), 43 of 142 (30%) were HIV positive, 38 of 142 (27%) had been diagnosed and treated for syphilis in the past, and 11 of 142 (8%) presented with symptoms (possible lesions of primary or secondary syphilis). Thirteen (9%, 95% CI=4.4 to 13.9) tested positive for syphilis on the day of presentation. MSM who were symptomatic (genital ulcer or body rash), HIV positive or had a history of syphilis were significantly more likely to test positive for syphilis (OR=51.88, 95% CI: 3.01 to 893.14, p=0.007). CONCLUSIONS: We have shown that in our clinic-based population of MSM who presented as sexual contacts of syphilis, the factors associated with testing positive for syphilis were: having HIV, having a history of syphilis or presenting with symptoms (possible lesions of primary or secondary syphilis). These factors could be used to rationalise antibiotic treatment among MSM presenting as sexual contacts of syphilis. Further research is needed to validate this finding in other populations of MSM and people affected by syphilis.

Factors Associated With Pediatric Burn Clinic Follow-up After Emergency Department Discharge.

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within 1 week. A total of 196 patients (Mage = 5.5 years; 54% male) were included in analyses. Average % TBSA was 1.9 (SD = 1.5%). One third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (odds ratio [OR] = 1.00; 95% confidence interval [CI]: [0.99-1.00], P = .045), patients with superficial burns (OR = 9.37; 95% CI: [2.50-35.16], P = .001), patients with smaller % TBSA (OR = 1.37; 95% CI: [1.07-1.76], P = .014), and patients with Medicaid insurance (OR = 0.22; 95% CI: [0.09-0.57], P = .002) or uninsured/unknown insurance (OR = 0.07; 95% CI: [0.02-0.26], P = .000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.