Time to start disease modifying drugs for adults with seropositive rheumatoid arthritis: results of the first year of the national New Zealand Rheumatology Association (NZRA) audit.

AIM: This audit describes variation in the time from referral to starting disease modifying drug (DMARD) for people with newly diagnosed seropositive rheumatoid arthritis (RA), how frequently this was within the recommended 6 weeks and whether regional, service-level or patient-level factors were associated with this variation. METHOD: Rheumatologists submitted data on new patients with a new diagnosis of rheumatoid factor and/or cyclic-citrullinated peptide antibody positive RA. The association between visit funding, ethnicity, socio-economic deprivation, rurality, local specialist staffing levels and the time to DMARD treatment was assessed using Cox proportional-hazard models. RESULTS: Data were collected on 355 patients over 12 months. Overall, 64.8% of patients commenced DMARD treatment within 6 weeks of referral and this was associated with rheumatologist FTE per 100,000 population (adjusted HR 2.47, 95%CI 1.27-4.81; p=0.008) and the rurality (Geographic Classification of Health [GCH]) of the patient (for R2 compared to U1 adjusted HR 0.20, 95%CI 0.09-0.43; p<0.001). There was no association between time to DMARD and ethnicity or socio-economic deprivation. CONCLUSION: There was significant variation in time to DMARD treatment, mainly related to variation in rheumatologist staffing levels and patient rurality. Rheumatologist staffing levels of 1.0 FTE/100,000 population was associated with 80% of patients meeting the recommended 6-week time to DMARD treatment.

Selective centralized booking as a low-cost alternative to centralized referral.

SummaryCentralized referral systems have been successfully implemented to shorten and equalize surgical wait times; however, ongoing expenses make sustaining these projects challenging. We trialed a low-cost centralized booking project for hernia surgery in a community hospital from July to November 2019. Eligible patients (i.e., those with visible or palpable inguinal or umbilical hernias who were agreeable to an open mesh repair) were booked with the first available surgeon after initial consultation. Centrally booked patients with either inguinal or umbilical hernias waited a mean of 82 (standard deviation [SD] 32) and 80 (SD 66) days, respectively, while those who did not use the centralized system waited 137 (SD 89) and 181 (SD 92) days, respectively. Centralized booking increased operating room utilization as a larger pool of patients was available to call when last-minute cancellation occurred; centralized booking also effectively equalized wait-lists among 6 surgeons. Selective centralized booking is a promising concept that led to more efficient utilization of available operating room time with a significant decrease in wait times; this system could potentially improve access for all patients awaiting general surgery without requiring additional funding.

Acceptance of electronic referrals across the Kingdom of Saudi Arabia: results from a national e-health database.

Introduction: An effective referral system is necessary to ensure quality and an optimum continuum of care. In the Kingdom of Saudi Arabia, an e-referral system known as the Saudi Medical Appointments and Referrals Centre (SMARC), has been fully functioning since 2019. This study aims to explore the rate of medical e-referral request acceptance in the KSA, and to study the factors associated with acceptance. Methods: This period cross-sectional study utilised secondary collected data from the SMARC e-referral system. The data spans both 2020 and 2021 and covers the entirety of the KSA. Bivariate analyses and binary logistic regression analyses were performed to compute adjusted Odds Ratios (aORs) and 95% confidence intervals. Results: Of the total 632,763 referral requests across the 2 years, 469,073 requests (74.13%) were accepted. Absence of available machinery was a significant predictor for referral acceptance compared to other reasons. Acceptance was highest for children under 14 with 28,956 (75.48%) and 63,979 (75.48%) accepted referrals, respectively. Patients requiring critical care from all age groups also had the highest acceptance including 6,237 referrals for paediatric intensive care unit (83.54%) and 34,126 referrals for intensive care unit (79.65%). All lifesaving referrals, 42,087 referrals, were accepted (100.00%). Psychiatric patients were observed to have the highest proportion for accepted referrals with 8,170 requests (82.50%) followed by organ transplantations with 1,005 requests (80.92%). Sex was seen to be a significant predictor for referrals, where the odds of acceptances for females increased by 2% compared to their male counterparts (95% CI = 1.01-1.04). Also, proportion of acceptance was highest for the Eastern business unit compared to all other units. External referrals were 32% less likely to be accepted than internal referrals (95% CI = 0.67-0.69). Conclusion: The current findings indicate that the e-referral system is mostly able to cater to the health services of the most vulnerable of patients. However, there remains areas for health policy improvement, especially in terms of resource allocation.

Assessment of eye health programme reach by comparison with rapid assessment of avoidable blindness (RAAB) survey data, Talagang, Pakistan.

BACKGROUND: The purpose of this study was to quantify how much of the burden of visual impairment (VI) and unmet need in Talagang, identified by Rapid Assessment of Avoidable Blindness (RAAB) survey data, has been addressed by Community Eye Health (CEH) programme efforts. METHODS: A RAAB survey was carried out in November 2018, with 2,824 participants in Talagang Tehsil, Punjab, Pakistan, aged 50 and over. Census data were used to extrapolate survey data to the population. Alongside this, a CEH programme was launched, consisting of community eye screening, and onward referral to rural health centres, secondary or tertiary ophthalmological services, as required. This health intervention aimed to address the eye care needs surfaced by the initial survey. From 2018 to 2022, 30,383 people aged 50 or over were screened; 14,054 needed referral to further steps of the treatment pathway and more detailed data collection. Programme data were compared to estimates of population unmet needs. Main outcome measures were prevalence of VI, and proportion of need met by CEH Programme, by cause and level of VI. RESULTS: Among those aged 50 and over, 51.0% had VI in at least one eye. The leading causes were cataract (46.2%) and uncorrected refractive error (URE) (25.0%). In its first four years, the programme reached an estimated 18.3% of the unmet need from cataract, and 21.1% of URE, equally in both men and women. CONCLUSIONS: Robustly collected survey and programme data can improve eye health planning, monitoring and evaluation, address inequities, and quantify the resources required for improving eye health. This study quantifies the time required to reach eye health needs at the community level.

Diagnosis and presenting features of autoimmune hepatitis at a central referral hospital in South Africa.

Introduction Autoimmune hepatitis (AIH) has scarcely been reported on in patients of black African descent. Similarly, few studies have focused on the relationship between AIH and Human-Immunodeficiency Virus (HIV) infection. Aim We aim to describe the presenting features of AIH from a single referral centre in a Sub-Sahara African setting. We also compare the presenting features of HIV-infected and HIV-uninfected patients. Methods This study was a retrospective chart review. Patients were included if they fulfilled criteria for the International AIH Group simplified score for probable or definite AIH, were 18 years or older at inclusion, and attended the adult Gastroenterology clinic at Inkosi Albert Luthuli Central Hospital (IALCH) for the period 1/1/2015 to 31/12/2020 on at least 2 occasions. Results Forty cases were included, of which 33 (82.5%) were female and 33 (82.5%) were black African. Median age at diagnosis was 26 years. A diagnosis of a coexistent autoimmune disease was made in 22.5% of patients, with Systemic Lupus Erythematosus (SLE) being the most common (12.5%). Sixteen patients were HIV-infected, all of whom were female (p =0.03), with a significantly older age of disease onset as compared to their HIV-uninfected counterparts (median age 38 vs 17.5 years, p <0.001). Conclusion AIH is a disease most commonly affecting young females. Female sex and older age of onset is associated with AIH in HIV-infected individuals.

Diagnostic Accuracy of a Mobile AI-Based Symptom Checker and a Web-Based Self-Referral Tool in Rheumatology: Multicenter Randomized Controlled Trial.

BACKGROUND: The diagnosis of inflammatory rheumatic diseases (IRDs) is often delayed due to unspecific symptoms and a shortage of rheumatologists. Digital diagnostic decision support systems (DDSSs) have the potential to expedite diagnosis and help patients navigate the health care system more efficiently. OBJECTIVE: The aim of this study was to assess the diagnostic accuracy of a mobile artificial intelligence (AI)-based symptom checker (Ada) and a web-based self-referral tool (Rheport) regarding IRDs. METHODS: A prospective, multicenter, open-label, crossover randomized controlled trial was conducted with patients newly presenting to 3 rheumatology centers. Participants were randomly assigned to complete a symptom assessment using either Ada or Rheport. The primary outcome was the correct identification of IRDs by the DDSSs, defined as the presence of any IRD in the list of suggested diagnoses by Ada or achieving a prespecified threshold score with Rheport. The gold standard was the diagnosis made by rheumatologists. RESULTS: A total of 600 patients were included, among whom 214 (35.7%) were diagnosed with an IRD. Most frequent IRD was rheumatoid arthritis with 69 (11.5%) patients. Rheport's disease suggestion and Ada's top 1 (D1) and top 5 (D5) disease suggestions demonstrated overall diagnostic accuracies of 52%, 63%, and 58%, respectively, for IRDs. Rheport showed a sensitivity of 62% and a specificity of 47% for IRDs. Ada's D1 and D5 disease suggestions showed a sensitivity of 52% and 66%, respectively, and a specificity of 68% and 54%, respectively, concerning IRDs. Ada's diagnostic accuracy regarding individual diagnoses was heterogenous, and Ada performed considerably better in identifying rheumatoid arthritis in comparison to other diagnoses (D1: 42%; D5: 64%). The Cohen κ statistic of Rheport for agreement on any rheumatic disease diagnosis with Ada D1 was 0.15 (95% CI 0.08-0.18) and with Ada D5 was 0.08 (95% CI 0.00-0.16), indicating poor agreement for the presence of any rheumatic disease between the 2 DDSSs. CONCLUSIONS: To our knowledge, this is the largest comparative DDSS trial with actual use of DDSSs by patients. The diagnostic accuracies of both DDSSs for IRDs were not promising in this high-prevalence patient population. DDSSs may lead to a misuse of scarce health care resources. Our results underscore the need for stringent regulation and drastic improvements to ensure the safety and efficacy of DDSSs. TRIAL REGISTRATION: German Register of Clinical Trials DRKS00017642; https://drks.de/search/en/trial/DRKS00017642.

Specialist care visits outside the hospital by South Australian older adults.

BACKGROUND: Limited access to specialist medical services is a major barrier to healthcare in rural areas. We compared rural-urban specialist doctor consultations outside hospital by older adults (≥ 60 years) across South Australia. METHODS: Cross-sectional data were available from the South Australia's Department of Health. The Modified Monash Model (MM1-7) of remoteness was used to categorize data into rural (MM 3-4), remote (MM5-7), and urban (MM1-MM2) of participants in urban and non-urban South Australia. The analysis was conducted on older adults (n = 20,522), self-reporting chronic physical and common mental health conditions. RESULTS: Specialist doctor consultation in the past 4 weeks was 14.6% in our sample. In multivariable analysis, increasing age (odds ratio 1.3, 95% CI: 1.2-1.4), higher education (odds ratio 1.5, 95% CI: 1.3-1.9), physical health conditions [diabetes (odds ratio 1.2, 95% CI: 1.1-1.3); cancer (odds ratio1.8, 95% CI: 1.7-2.0); heart disease (odds ratio 1.9, 95% CI: 1.6-2.1)], and common mental disorders [depression (odds ratio 1.3, 95% CI: 1.1-1.5); anxiety (odds ratio 1.4, 95% CI: 1.1-1.6)] were associated with higher specialist care use. Specialist care use among rural (odds ratio 0.8, 95% CI: 0.6-0.9), and remote (odds ratio 0.8, 95% CI: 0.7-0.9) older people was significantly lower than their urban counterparts after controlling for age, education, and chronic disease. CONCLUSION: Our findings demonstrate a disparity in the use of out of hospital specialist medical services between urban and non-urban areas.

Last general practitioner consultation during the final month of life: a national medical record review of suicides in Sweden.

OBJECTIVES: Individuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide. DESIGN: A nationwide retrospective explorative study investigating medical records. SETTING: Primary care in Sweden. PARTICIPANTS: Individuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death. RESULTS: The study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years ± 19. Patients in the NPC group were older (NPC: 63 years ± 19 vs. PC: 53 years ± 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020). CONCLUSION: A high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs' management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms. STRENGTHS AND LIMITATIONS OF THIS STUDY: The National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs' documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group.

The impact of patient registration on utilisation and quality of care: a propensity score matching and staggered difference-in-differences analysis of a cohort of 16,775 people with type 2 diabetes.

BACKGROUND: In 2012, Luxembourg introduced a Referring Doctor (RD) policy, whereby patients voluntarily register with a primary care practitioner, who coordinates patients' health care and ensures optimal follow-up. We contribute to the limited evidence base on patient registration by evaluating the effects of the RD policy. METHODS: We used data on 16,775 people with type 2 diabetes on oral medication (PWT2D), enrolled with the Luxembourg National Fund from 2010 to 2018. We examined the utilisation of primary and specialist outpatient care, quality of care process indicators, and reimbursed prescribed medicines over the short- (until 2015) and medium-term (until 2018). We used propensity score matching to identify comparable groups of patients with and without an RD. We applied difference-in-differences methods that accounted for patients' registration with an RD in different years. RESULTS: There was low enrolment of PWT2D in the RD programme. The differences-in-differences parallel trends assumption was not met for: general practitioner (GP) consultations, GP home visits (medium-term), HbA1c test (short-term), complete cholesterol test (short-term), kidney function (urine) test (short-term), and the number of repeat prescribed cardiovascular system medicines (short-term). There was a statistically significant increase in the number of: HbA1c tests (medium-term: 0.09 (95% CI: 0.01 to 0.18)); kidney function (blood) tests in the short- (0.10 (95% CI: 0.01 to 0.19)) and medium-term (0.11 (95% CI: 0.03 to 0.20)); kidney function (urine) tests (medium-term: 0.06 (95% CI: 0.02 to 0.10)); repeat prescribed medicines in the short- (0.19 (95% CI: 0.03 to 0.36)) and medium-term (0.18 (95% CI: 0.02 to 0.34)); and repeat prescribed cardiovascular system medicines (medium-term: 0.08 (95% CI: 0.01 to 0.15)). Sensitivity analyses also revealed increases in kidney function (urine) tests (short-term: 0.07 (95% CI: 0.03 to 0.11)) and dental consultations (short-term: 0.06, 95% CI: 0.00 to 0.11), and decreases in specialist consultations (short-term: -0.28, 95% CI: -0.51 to -0.04; medium-term: -0.26, 95% CI: -0.49 to -0.03). CONCLUSIONS: The RD programme had a limited effect on care quality indicators and reimbursed prescribed medicines for PWT2D. Future research should extend the analysis beyond this cohort and explore data linkage to include clinical outcomes and socio-economic characteristics.

How "Breast Aware" are the Indian Women? A Study among the Women Visiting a Tertiary Care, Referral, and Teaching Hospital.

INTRODUCTION: "Who will educate us" lamented a School Principal after she took part in our study and education session. There is palpable low breast cancer (BC) literacy with rising incidence and disproportionate mortality rates. METHODOLOGY: Breast Cancer Awareness Measure (BCAM) developed by Cancer Research UK was administered to 944 women. BCAM measures knowledge, age-related risk, and reported frequency of breast checking and other components. A woman is BC aware if she identified five or more nonlump symptoms, age-related risk, and reported breast checking once a week/month. At the end, each participant was given "Be Breast Aware" education; what/how to look for demonstrated on a model. RESULTS: 2.8% health professionals. 3.1% BC survivors. 78.8% had lump knowledge and 55.3% had non-lump knowledge of BC, 10% had age-related risk knowledge. 24.3% check breasts once a week/month. 41.9% aware BC is common after 50 years. 14/944 (1.5%) had BC awareness. 59.9% had breast symptoms, but never consulted a doctor, 31.1% were embarrassed, and 29.4% were scared to consult. Nearly 43% heard of breast screening, 28.4% had mammography, 26.3% had ultrasound. About 44.1% knew family history risk. Those practicing breast checking looked for a size change (24.5%), nipple position (17.4%), discharge (22.1%), pain (32.5%), and lump (24.7%) in standing (17.8%), supine (8.5%) using finger pads (15.8%) fingertips (21.6%), using circular movements (16.4%), and pinching breast tissue (19.6%). CONCLUSION: Health-care workers and BC survivors lack breast awareness which is alarming and indicates the need for BC awareness and post-BC treatment follow-up care education in these two groups and the general population. Some practice the wrong method (e.g., pinching tissue) of breast checking, which may lead to anxiety and unnecessary investigative costs. "Be Breast Aware" education based on the National Health Service 5-point plan given to 944 participants.

Résumé Introduction:'Qui nous éduquera ?' s'est lamentée une directrice d'école après avoir participé à notre séance d'étude et d'éducation. Il existe un faible niveau de connaissances sur le cancer du sein, avec une incidence croissante et des taux de mortalité disproportionnés.Méthodologie:La mesure de sensibilisation au cancer du sein (B-CAM) développée par Cancer Research UK a été administrée à 944 femmes. B-CAM mesure les connaissances, le risque lié à l'âge et la fréquence signalée de l'auto-examen des seins, ainsi que d'autres composants. Une femme est consciente du cancer du sein si elle a identifié au moins 5 symptômes non nodulaires, un risque lié à l'âge et si elle a signalé un auto-examen des seins une fois par semaine/mois. À la fin, chaque participante a reçu une éducation 'Be Breast Aware'; comment auto-examiner les seins a été démontré sur un modèle.Résultats:2,8% de professionnels de santé. 3,1 % de survivantes du cancer du sein. 78,8 % avaient une connaissance des symptômes nodulaires et 55,3 % avaient une connaissance non nodulaire du cancer du sein, et 10 % avaient une connaissance des risques liés à l'âge. 24,3 % vérifient leurs seins une fois par semaine/mois. 41,9 % savent que le cancer du sein est courant après 50 ans. 14/944 (1,5 %) étaient sensibilisées au cancer du sein. 59,9% avaient des symptômes mammaires mais n'avaient jamais consulté de médecin, 31,1% étaient gênées, 29,4% avaient peur de consulter. 43 % ont entendu parler du dépistage du cancer du sein, 28,4 % de la mammographie, 26,3 % de l'échographie. 44,1 % connaissaient le risque lié aux antécédents familiaux. Ceux qui pratiquent l'auto-examen des seins ont examiné le changement de taille des seins (24,5 %), la position du mamelon (17,4 %), l'écoulement (22,1 %), la douleur (32,5 %) et la grosseur (24,7 %) en position debout (17,8 %) en décubitus dorsal (8,5 %) en utilisant le bout des doigts (15,8 %) le bout des doigts (21,6 %), en utilisant des mouvements circulaires (16,4 %) et en pinçant le tissu mammaire (19,6 %)Conclusion:les travailleurs de la santé et les survivantes du cancer du sein manquent de sensibilisation aux seins, ce qui est alarmant et indique la nécessité pour la sensibilisation au cancer du sein et l'éducation aux soins de suivi post-traitement dans ces deux groupes et la population générale. Certaines pratiquent une mauvaise méthode d'auto-examen des seins, ce qui peut entraîner de l'anxiété et des coûts d'investigation inutiles. Éducation 'Be Breast Aware' basée sur le plan en 5 points du NHS dispensé à 944 participantes.

Two decades of recipient and donor referrals for heart transplantation to Groote Schuur Hospital, Cape Town, South Africa: A retrospective study.

BACKGROUND: Heart transplantation in South Africa faces numerous challenges related to organ scarcity and unequal access to advanced heart therapy. There is an urgent need to analyse the current transplant referral pathway to optimise equitable access to transplantation. OBJECTIVES: To provide an audit of heart transplant referrals to Groote Schuur Hospital, Cape Town, over a 23-year period, focusing on patient demographics, indications for referral, waiting-list dynamics, and transplant referral outcomes. METHODS: The study utilised a retrospective patient folder review for the period 1 January 1997 - 31 December 2019 and audited the trends in heart transplant referrals and associated outcomes of the referral at a tertiary academic hospital. RESULTS: A total of 625 recipients were referred for heart transplantation, with the majority being male (n=412; 65.9%), while gender was undocumented for 69 cases (11.0%). The mean age was 38.1 (14.6) years, and 153 (24.5%) were listed for transplant, while 215 (34.4%) were deemed ineligible for listing. Contraindications for listing included social (n=106; 49.3%), medical (n=83; 38.6%) and psychological (n=26; 12.0%) factors, while 134 patients (21.4%) were considered too well. Poor social circumstances (n=38; 39.6%), poor insight (n=28; 29.2%) and poor compliance (n=21; 21.9%) were the most common non-medical reasons for not listing recipients, while obesity (n=30; 31.3%) and smoking (n=23; 24.0%) were notable medical contraindications. Forty-nine patients (7.8%) died during work-up, while 130 (85.0%) of the listed patients received a heart transplant. Of the 429 donor referrals, 139 (32.4%) were accepted for organ procurement. Reasons for declining donors included unsuitability for transplantation (30.3%), lack of capacity (1.8%), and recipient-donor mismatch (66.9%). CONCLUSION: Three-quarters of the referred patients were deemed unsuitable for heart transplantation for medical and/or social reasons. The ratio of referral to listing has decreased over time. However, once listed, the likelihood of receiving a transplant was high.

An analysis of referral patterns of traumatic brain injury at Groote Schuur Hospital Trauma Centre.

BACKGROUND: Traumatic brain injury (TBI) can result in significant morbidity and mortality if not diagnosed in a timely manner. Brain computed tomography (CT) is the diagnostic gold standard but is of limited availability in most South African public hospitals, resulting in transfer of TBI patients to tertiary hospitals. OBJECTIVE: To describe the referral patterns and outcomes of patients with TBI referred to Groote Schuur Hospital Trauma Centre. METHODS: This was a retrospective audit of all patients admitted to the Trauma Centre who had a brain CT scan for suspected TBI between 1 February 2022 and 31 March 2022. Demographic data (age, sex), mechanism of injury and Glasgow Coma Score were recorded. Referral pathways were determined, and final disposition of patients was recorded. RESULTS: A total of 522 patients had a brain CT for TBI. Of these, 314 (60.1%) were referred from other hospitals. CT scan was abnormal in 178 (34.1%) patients. Three hundred and two (58.6%) were discharged home within 24 hours. The mean time between referral and CT scan was 13 hours. CONCLUSION: More than half of patients referred for a CT scan were discharged from the Trauma Centre within 24 hours of admission, which indicates additional costs and inefficiencies in the health system. These data are useful to guide resource planning and allocation for district hospitals, since less expensive point-of-care modalities now exist to diagnose TBI, and which are useful in indicating the prognosis of patients.

Streamlining lung cancer management in Nova Scotia amid COVID-19: pooled triaging for expedited curative-intent oncologic surgery.

BACKGROUND: The effect of the COVID-19 pandemic on the diagnosis and management of lung cancer in Canada is not fully understood. We sought to quantify the provincial volume of diagnostic imaging, thoracic surgeon referrals, time to surgery after referral, and pathologic staging for curative surgery in the context of the pandemic, as well as explore the effect of a pooled patient model, which was implemented to prioritize surgeries for lung cancer and mitigate the effects of the pandemic. METHODS: We conducted a retrospective cohort study of patients who underwent diagnostic imaging in Nova Scotia and were subsequently referred to a thoracic surgeon at the province's only tertiary care centre for surgical management of their primary lung cancer before (Mar. 1, 2019, to Feb. 29, 2020) and during (Mar. 1, 2020, to Feb. 28, 2021) the COVID-19 pandemic. We conducted a survey to capture the patient and surgeon experience with a pooled patient model of managing surgical oncology cases. RESULTS: Compared with the pre-COVID-19 period, the overall volume of chest radiography and chest computed tomography decreased by 30.9% (p < 0.001) and 18.7% (p = 0.002), respectively, in the COVID-19 period. Thoracic surgeon referrals, operative approach, extent of resection, length of hospital stay, and pathologic staging did not significantly differ. Time from referral to surgery was significantly shorter during the COVID-19 period (mean 196.8 d v. 157.9 d, p = 0.04). A pooled patient approach contributed to positive patient satisfaction. CONCLUSION: The COVID-19 pandemic was associated with reductions in rates of diagnostic imaging and referrals to thoracic surgeons for management of pulmonary cancer. A pooled patient model was used to mitigate the effects of the pandemic on lung cancer management and was positively received by patients. An extended study period is needed to determine the full effect of this redistribution of resources.

Quantification of referrals received at two emergency-capable hyperbaric medicine centers.

Emergency hyperbaric oxygen treatment capability is limited in the United States, and there is little documentation of calls received by centers available 24 hours a day, seven days a week, 365 days a year. Our study aimed to calculate the number of calls received for urgent hyperbaric oxygen (HBO2). We logged calls from two HBO2 chambers on the East Coast of the United States that serve a densely populated region in 2021. The total number of emergency calls was 187 at the University of Maryland (UMD) and 127 at the University of Pennsylvania (UPenn). There were calls on 180/365 (46%) days during the study period at UMD and 239/365 (63%) days at UPenn. The most common indication was carbon monoxide toxicity. The peak month of calls was March. Emergency HBO2 calls are common, and more centers must accept emergency cases. Data from geographically diverse centers would add generalizability to these results and capture more diving-related emergencies.

Towards a flexible and personalised development of veterinarians and veterinary nurses working in a companion animal referral care setting.

In the Netherlands, the demand for veterinarians and veterinary nurses (VNs) working within referral care is rapidly growing and currently exceeds the amount of available board-certified specialists. Simultaneously, a transparent structure to guide training and development and to assess quality of non-specialist veterinarians and VNs working in a referral setting is lacking. In response, we developed learning pathways guided by an entrustable professional activity (EPA) framework and programmatic assessment to support personalised development and competence of veterinarians and VNs working in referral settings. Between 4 and 35 EPAs varying per discipline (n = 11) were developed. To date, 20 trainees across five disciplines have been entrusted. Trainees from these learning pathways have proceeded to acquire new EPAs in addition to their already entrusted set of EPAs or progressed to specialist training during (n = 3) or after successfully completing (n = 1) the learning pathway. Due to their outcome-based approach, the learning pathways support flexible ways of development.

Interpersonal violence against people with intellectual disabilities in São Paulo, Brazil: characteristics of victims, perpetrators and referrals.

INTRODUCTION: Interpersonal violence is a phenomenon that can occur with different people and conditions. However, people with intellectual disabilities have increased vulnerability to this problem, with potential risks to their health and well-being. The aim of this study was to identify the sociodemographic characteristics of people with disabilities who have been victims of interpersonal violence, the profile of the perpetrators and the measures taken after the victims have been cared for. METHODS: This is an exploratory, descriptive, cross-sectional study using the Interpersonal Violence Notification Forms entered into the Brazilian Ministry of Health's Notifiable Diseases Information System. The city of São Paulo was chosen as the setting because it is the largest city in Latin America and has a faster data processing system than other cities. The period covered notifications made between 2016 and 2022. The information was collected between October and November 2023 and a univariate statistical analysis was carried out. Fisher's exact test was used, with a significance level of 5% (α = 0.05). RESULTS: There were 4,603 notifications against people with intellectual disabilities in the period. The forms of physical violence, neglect/abandonment and psychological/moral violence were more frequent in the 15-19 age group, while sexual violence was more frequent in the 10-14 age group (p < 0.001). The sex most often attacked was female in all the forms investigated (p < 0.001) and the skin colors of the most victimized people were black and/or brown, except in cases of neglect/abandonment (p = 0.058). Most of the victims had little schooling (p = 0.012). The aggressions were committed by one person (p < 0.001), known or related to the victim, such as mother or father, except in cases of sexual violence, where strangers were the main perpetrators (p < 0.001). The sex of the perpetrator was male, except in cases of neglect and/or abandonment (p < 0.001), and the age was between 25 and 29 (p = 0.004). In cases of sexual violence, rape was the most frequent and the procedures carried out were blood collection followed by prophylaxis for Sexually Transmitted Infections (STIs) were the main procedures carried out by health professionals (p = 0.004). The majority of referrals made after receiving care were to the health and social assistance network, with few referrals to bodies such as the human rights reference center, guardianship council and police stations (p < 0.001). CONCLUSION: People with intellectual disabilities are highly vulnerable to the forms of violence studied, especially children and adolescents, black or brown, with low levels of education. The perpetrators are usually close people, male and older than the victims. The referrals made by health professionals did not prioritize the victim's safety and the guarantee of human rights. Lines of care for the health of victims of violence should be implemented, taking into account special aspects, such as people with intellectual disabilities, whose search for help can be difficult.

Designing a core data set for benign hysterectomy registration system and its implementation in a referral teaching hospital in Northwest Iran.

BACKGROUND AND AIMS: Although minimally invasive hysterectomy offers advantages, abdominal hysterectomy remains the predominant surgical method. Creating a standardized dataset and establishing a hysterectomy registry system present opportunities for early interventions in reducing volume and selecting benign hysterectomy methods. This research aims to develop a dataset for designing benign hysterectomy registration system. METHODS: Between April and September 2020, a qualitative study was carried out to create a data set for enrolling patients who were candidate for hysterectomy. At this stage, the research team conducted an information needs assessment, relevant data element identification, registry software development, and field testing; Subsequently, a web-based application was designed. In June 2023the registry software was evaluated using data extracted from medical records of patients admitted at Al-Zahra Hospital in Tabriz, Iran. RESULTS: During two months, 40 patients with benign hysterectomy were successfully registered. The final dataset for the hysterectomy patient registry comprise 11 main groups, 27 subclasses, and a total of 91 Data elements. Mandatory data and essential reports were defined. Furthermore, a web-based registry system designed and evaluated based on data set and various scenarios. CONCLUSION: Creating a hysterectomy registration system is the initial stride toward identifying and registering hysterectomy candidate patients. this system capture information about the procedure techniques, and associated complications. In Iran, this registry can serve as a valuable resource for assessing the quality of care delivered and the distribution of clinical measures.

Exploring patient referral practices of traditional healthcare practitioners in Soshanguve, Gauteng Province, South Africa.

Introduction: It may be necessary for healthcare professionals to refer patients to other professionals and institutions that are able to provide the care needed by patients, depending on the severity each case presents, healthcare requirements, and resources available to offer care. In healthcare generally, patient referral is standard procedure; however, in South Africa, referral patterns between allopathic and traditional healthcare practitioners are unknown, and this is a problem yet to be addressed. Objectives: The study objective was to explore patient referral practices from the perspectives of traditional healthcare practitioners of South Africa. Methods: A qualitative, exploratory and descriptive design was employed to collect data from 11 traditional healthcare practitioners who were sampled using snowball sampling. An individual semi structured interview schedule was used to collect data. Content analysis was used to analyze the data. Results: Patient referral was common practice in traditional health practices, however not reciprocal between the traditional and allopathic healthcare. Several indications for patient referral to allopathic healthcare practitioners included management of chronic conditions amongst others. Discussion: Patient referral being an important part of healthcare practices should be promoted and regulation and traditional health practices improved to promote safe referral practices and curb unsafe self-referrals by patients.

Adherence to the ISHLT Protocol for the Referral of Patients with Idiopathic Pulmonary Fibrosis to the Transplantation Center among of Czech Centers for Interstitial Lung Diseases.

There are limited data on referral rates and the number of patients with idiopathic pulmonary fibrosis (IPF) who are eligible for lung transplantation. The aim of the present study was to assess adherence to the consensus of the International Society for Heart and Lung Transplantation (ISHLT) for the referral of patients with IPF among Czech interstitial lung disease (ILD) centers. Czech patients who were diagnosed with IPF between 1999 and 2021 (n = 1584) and who were less than 65 years old at the time of diagnosis were retrospectively selected from the Czech Republic of the European Multipartner Idiopathic Pulmonary Fibrosis Registry (EMPIRE). Nonsmokers and ex-smokers with a body mass index (BMI) of <32 kg/m2 (n = 404) were included for further analyses. Patients with a history of cancer <5 years from the time of IPF diagnosis, patients with alcohol abuse, and patients with an accumulation of vascular comorbidities were excluded. The trajectory of individual patients was verified at the relevant ILD center. From the database of transplant patients (1999-12/2021, n = 541), all patients who underwent transplantation for pulmonary fibrosis (n = 186) were selected, and the diagnosis of IPF was subsequently verified from the patient's medical records (n = 67). A total of 304 IPF patients were eligible for lung transplantation. Ninety-six patients were referred to the transplant center, 50% (n = 49) of whom were referred for lung transplantation. Thirty percent of potentially eligible patients not referred to the transplant center were considered to have too many comorbidities by the reporting physician, 19% of IPF patients denied lung transplantation, and 17% were not referred due to age. Among Czech patients with IPF, there may be a larger pool of potential lung transplant candidates than has been reported to the transplant center to date.

Clinical characteristics and outcome of critically ill children referred to a tertiary hospital in Indonesia: a prospective observational study.

BACKGROUND: The clinical characteristics of pediatric critically ill patients who need referral to a tertiary hospital is often unknown in resource limited settings where constraints in diagnosis capacity, resources, and infrastructures are common. There is a need to increase insight in the characteristics of these patients for capacity building strengthening and appropriate resource allocation. The aim of this study was to describe the clinical characteristics and outcomes of critically ill children who are referred to a tertiary referral teaching hospital in Yogyakarta. METHODS: A prospective observasional study was carried out from July 1st, 2022 -January 31st, 2023 which included all critically ill pediatric patients who were referred through the Integrated Referral System (SISRUTE) to the Pediatric Intensive Care Unit (PICU) of dr. Sardjito hospital. We excluded patients who were referred with a request for admission to the PICU, but were not admitted to the PICU due to their stable condition and lack of the need for intensive care. RESULT: During the study period, we received 1046 emergency referral requests for pediatric patients via SISRUTE, of those, 562 (53.7%) patients were critically ill. The reasons of PICU referral request were the need of solely intensive care 504 (89.7%), the need of multidisciplinary team care, including intensive care 57 (10.1%) and parents request 1 (0.3%). The pre-referral emergency diagnosis was shock 226 (40.3%), respiratory distress/failure 151 (26.7%), central nervous system (CNS) dysfunction 135 (24.1%), trauma 33 (5.9%) and sepsis 17 (3%). Of the 562 critically ill PICU referral requests, 473 (84.2%) requests were accepted. One hundred and eighty-one (58.7%) patients were finally admitted to the PICU, 125 (40.3%) admitted to our regular ward due to stable condition, 4 (1.3%) patients died in Emergency Departement (ED). The remaining accepted patients on request did not arrive in our facility due to various reasons. The mean (SD) response time was 9.1 (27.6) minutes. The mean (SD) transfer time was 6.45 (4.73) hours. Mean (SD) PICU and hospital length of stay was 6.7 (8.3) days and 10.2 (9.2) days respectively. PICU and hospital mortality was 24.3% and 29.7%, respectively. CONCLUSION: The mortality rate for critically ill pediatric patients referred to a tertiary PICU still high, with shock being the most common pre-referral emergency diagnosis. There is a discrepancy between the referring hospital's and the referral hospital's indication for PICU admission. The time required to reach the referral hospital is quite lengthy.