A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.

Two new species of Megalota from the Bahamas (Lepidoptera: Tortricidae: Olethruetinae).

Two new species of Megalota Diakonoff, 1966 are described and illustrated from the Bahamas: M. bahamana Brown Matthews, new species, and M. insularis Brown and Matthews, new species. The two are among the 65 or so species of Tortricidae recorded from the Bahamas during an inventory of the Lepidoptera of the archipelago initiated in 2010.

Two new species of Eucosmini from the Bahamas (Lepidoptera: Tortricidae).

Recent surveys to document the poorly known moth fauna of the Bahamas have resulted in the collection of more than 60 morphospecies of Tortricidae. Among these are several Eucosmini, including undescribed representatives of Eucosma and Pelochrista that are similar to several species present in the southeastern United States. Eucosma bahamae, sp.n., a member of the E. refusana group, and Pelochrista wrighti, sp.n., a member of the P. canana group, are described and illustrated.

A new species of Oxyptilus Zeller from the southwestern United States (Lepidoptera, Pterophoridae).

Oxyptilus eleaneraesp. n., is described from New Mexico, Arizona, and Southwest Texas, and compared with the only other Oxyptilus occurring in the Nearctic Region, O. delawaricus Zeller. A redescription is provided for O. delawaricus. Adults and male and female genitalia are illustrated for both species. Key morphological characters, distributions, and relationships within the genus are discussed.

Description of the natural history and immature stages of Postplatyptilia caribica Gielis in Puerto Rico (Lepidoptera: Pterophoridae).

Observations of the life history of a plume moth, Postplatyptilia caribica Gielis are presented along with an adult diagnosis and descriptions of the final instar larva and pupa. The species was previously known only from two female specimens. Illustrations are provided for the adults and immatures, including both male and female genitalia. Morphological characters of the adults and immatures are discussed and compared with other members of the tribe Platyptiliini. Identification of adults and immatures is especially important because one of the larval hostplants, Gesneria pauciflora Urb., is a threatened endemic species of Puerto Rico. The plant family Gesneriaceae is a new addition to the known plant families used by Pterophoridae.

What is the best approach to the teenage patient presenting with nonclassical congenital adrenal hyperplasia: should we always treat with glucocorticoids?

Patients with Congenital adrenal hyperplasia due to partial deficiency in the enzyme 21-hydroxylase can present in childhood or adolescence with signs of adrenal androgen excess. Strategies to reduce the impact of androgen excess in females include cosmetic measures as well as antiandrogens and agents such as the combined oral contraceptive pill. Glucocorticoid may not be appropriate straightaway but can be introduced if other measures are ineffective or when pregnancy is planned.