Rationale, aims, and objectives: Post-hospitalization follow-up within 30 days following discharge has been shown to positively impact time to readmission, healthcare costs, and patient self-reported adherence and satisfaction. We aimed to improve resident satisfaction with the process of establishing post-hospitalization, primary care provider (PCP) follow-up. Methods: In this quality improvement study we surveyed all internal medicine residents at our institution regarding their satisfaction with the process of establishing PCP follow-up at the time of hospital discharge. A streamlined process was developed and two subsequent interventions were enacted; a dedicated teaching session and distribution of pocket cards outlining the process. Residents were then surveyed following each intervention to assess for impact on overall satisfaction and burden of work. Results: Initially, 77.3% of residents were not satisfied with the process of establishing post-hospitalization PCP follow-up. Following the first intervention there was a trend towards increasing satisfaction rates by 16.7% (p= 0.20), and after the second intervention there was a statistically significant increase in satisfaction rates from baseline by 44% (p= 0.007). There was also a reduction in the feeling of workload burden associated with establishing PCP follow-up from 32% to 25%, and over 67% of participants either agreed or strongly agreed that the workload was not too burdensome. Conclusion: This quality improvement initiative established that resident physicians at our institution previously found the process of establishing PCP follow-up at the time of patient discharge both confusing and burdensome. Through the implementation of our interventions we were able to achieve our aims of improving resident satisfaction.

Background. Differential diagnosis of Low-back pain (LBP) is complex and a prominent health care issue at all Health-care levels; guidance may come from patients’ history cues and clinical examination signs. Human and animal studies report that lumbar radicular pain (LRP) may be diagnosed, at all care settings, by the evaluation of subjective responses of injured lumbar nerves to a strain applied at the buttock. The Buttock Applied Strain (BUAS-test) may guide the differential diagnosis of LBP. Following an ex-adiuvantibus criterion, clinical improvement of LRP, diagnosed with the BUAS-test and congruently treated, may support this test diagnostic ability. Methods. Among 258 LRP patients, positive at V1, to the BUAS-test (with/without positive Straight-Leg-Raising-Test, SLRT), the effect of gabapentin on painDETECT (PD) questionnaire and BPI outcomes was quantified in the follow-up visit (V2). We hypothesized that, at V2, >50% of the sample would present negative PD-outcome, significant (t-Test), and 2 points V2-V1 differences for each the BPI-item’s score. Multinomial-Logistic-Regression (MLR) and χ2 analyses were used to evaluate the PD-V2-outcomes’ dependence upon independent variables. Results. Of the sample, 77% reported Negative PD-V2-outcome. V2-V1 differences of all BPI-items were significant and >2 points. PD-V2-outcomes showed significant associations with SLRT-V1 and PD-V1, respectively, but not with gender, age group, or pain-site. MLR showed a significant relationship between SLRT-V1 and PD-V2 outcomes. Conclusions. Among LRP patients, diagnosed by the BUAS-test and treated with gabapentin, all prespecified endpoints were reached. These results may be considered a piece of ex-adiuvantibus evidence for the BUAS-test ability to diagnose LRP. While positive BUAS-test implies potential LRP, the co-presence with positive SLRT may imply a severer LRP condition. Further prospective research, in different settings and direct clinical measures, is needed.

Rationale, aims and objectives: The Getting It Right First Time (GIRFT) programme was set up to reduce unwarranted variation in healthcare practice and outcomes in England. The aim of this study was to investigate early changes in practice in urology based on the recommendations made. Key recommendations included: 1) to increase rates of day-case surgery for transurethral resection of bladder tumour (TURBT), 2) to reduce use of stenting as a primary procedure for emergency presentations with ureteric stones and 3) to reduce waiting times for male bladder outflow tract surgery following emergency presentation with urinary retention. Methods: Data on patient age, the treatment provider, dates of admission and discharge, diagnoses and procedures conducted were extracted from the Hospital Episodes Statistics database from January 2014 to December 2019. The dates of visits by members of the GIRFT team was taken as the intervention point. Interrupted time series analysis was used to identify trends pre- and post-intervention. Results: There was evidence of a significant increase in the proportion of patients seen as day-cases for TURBT and decreased use of stents and increased use of ureteroscopy or extracorporeal shock-wave lithotripsy on first presentation with ureteric stones following GIRFT visits. However, there was no significant change in waiting times for surgery to treat patients who had an emergency presentation with urinary retention. Conclusions: In the first 18 months following the last of the GIRFT visits, there is some evidence that the recommendations made are already having an impact on clinical practice. The reasons why some recommendation appear to be harder to implement requires further investigation.

A common perception about Multidisciplinary team (MDT) approach is that it improves quality of care to hospitalized patients, particularly those who are dying. However, there is paucity of information on challenges in implementing such approach in end-of-life care (eolc). The present study explores barriers to MDT functioning in the context of ‘eolc’. Data collected through interviews of physicians, nurses and other staff, and review of case records of deceased patients of a multispecialty hospital in Kolkata (India) suggest that the MDT approach fails to live up to its rhetoric. One of the major challenges is professional boundary that is intrinsic to MDT. Due to this, specialist physicians fail to make consensus end-of-life decisions by overcoming disciplinary boundaries. Moreover, holistic caregiving is compromised in the physician-dominant medical team, where nurses and other non-clinical caregivers feel marginalized. The hospital environment is also not conducive to multidisciplinary teamwork. Application of a disease-specific treatment protocol in ‘eolc’ settings aggravates team coordination. ‘Eolc’ referrals and care transfers becomes very difficult. Dying patients and their families are specially affected by such discordant care. Based on the findings, the study suggests that while team approach is imperative to effective ‘eolc’, there is a need to shift focus from multidisciplinary to transdisciplinary approach to enhance care integration and patient-centric care to terminally ill patients.

Rationale and objective: Occupation-based practice (OBP) is a treatment approach unique to occupational therapy. It harnesses the power of occupation to achieve health and well-being. Most hand therapists are occupational therapists, however, current hand therapy treatment methods are component-based, focussing on physical impairments. This is despite an emerging body of evidence that supports the effectiveness of OBP with hand conditions. To explore the use of OBP in hand therapy, the knowledge, attitudes and practices (KAP) of South African occupational therapists towards OBP needed to be first established. There was no contextually-relevant instrument for this, thus this paper reports on the development processes of a new instrument to capture KAP in OBP in South African hand therapists. Method: Questionnaire development followed the Burns et al (2008) methodology. Items were identified following a comprehensive literature search. Face and content validity, clinical utility, and validation of the subsequent Afrikaans translation were undertaken by two purposively-selected sets of participants (experts and peers). Data collection involved cognitive interviewing, iterative email correspondence, face-to-face discussions, and member checking. Final adjustments to questionnaire wording were made through consensus discussion between the first and second authors. Results: Four therapists participated. Seventy-nine questionnaire items were retained, with three items being removed as they were unclear, or did not measure constructs appropriately for context. The final survey instrument had face and content validity and consisted of 63 KAP items and 16 demographic questions. Conclusion: This is believed to be the first instrument designed to capture valid information on KAP in OBP in hand therapy in South Africa. It will assist in identifying gaps in practice quality, and underpin design of effective strategies for education about, and implementation of, OBP within hand therapy. The instrument is suitable for adaptation to other fields of occupational therapy practice in South Africa, and internationally.

Rationale, aims, and objectives Pharmacological treatment for bronchiolitis is primarily supportive because bronchodilators, steroids, and antibiotics, show little benefit. Clinical studies have suggested that nebulized 3% HS is useful for infants with bronchiolitis. The aim of this study was to evaluate the cost-effectiveness of the HS nebulized in infant bronchiolitis in a middle-income tropical country Methods A decision tree model was used to estimate the cost-effectiveness of the use of nebulized hypertonic saline (3-7%) compared with treatment without hypertonic saline nebulization (control) in bronchiolitis. Cost data were obtained from a retrospective study on bronchiolitis from tertiary centers in Rionegro, Colombia, while utilities were collected from the literature. The analysis was carried out from a societal perspective. Results The control strategy was dominated by HS nebulized group. The expected costs per patient were US$ 200 (CI 95% US$ 178- 222) in the HS nebulized group and US$ 240 (CI 95% US$ 213- 267) in controls. The expected utilities were 0.923 (CI 95% 0.922- 0.924) in the HS nebulized group and 0.91 (CI 95% 0.918- 0.920) in controls. Sensitivity analyses of parameters in the model showed that the cost-effectiveness of HS was only sensitive to the probability of hospitalization. Conclusion The strategy treatment without hypertonic saline nebulization was dominated by the strategy with HS nebulized in infants with bronchiolitis. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other tropical countries.

BACKGROUND: the outbreak of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in more than 150000 infected individuals and more than 20000 deaths in Italy. Viral acute pneumonitis is the major cause of morbidity and mortality, but there is increasing evidence that COVID-19 patients show a variable degree of vascular complications, due to a possible hypercoagulability status. OBJECTIVE: to report thrombotic events in abdominal and lower-limb arteries of COVID-19 patients (abdominal aorta, superior mesenteric artery, femoral arteries, cardiac, spleen and kidney). METHODS: we retrospectively reviewed our clinical records of patients with confirmed SARS-CoV-2 infection, admitted from March 1st to April 6th, 2020, to a tertiary care center in Brescia, Italy. We selected five patients with major arterial thrombo-embolic manifestations. RESULTS AND CONCLUSION: In our opinion, arterial thrombotic events may be more common in COVID-19 patients than in general population, possibly resulting in rapid worsening of patient conditions.

Objective: Numerous clinical practice guidelines (CPGs) for the corona virus disease 2019 (COVID-19) have been developed since its outbreak. To date, however, the methodological quality of these guidelines has not been fully evaluated. Quality evaluation of the guidelines is to facilitate the clinic practitioners in diagnosis and treatment of the COVID-19. Methods: The evaluation was conducted by searching seven databases and government organizations websites (December 2019 to March 2020). Four assessors assessed the quality of the CPGs independently with the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. For domain scores (0-100%), >60% were considered of sufficient quality, and >80% of good quality. Results: Of 471 retrieved records, 20 guidelines were included. The median score for the domain of scope and purpose was 56.9% (range 40.3–90.3%) and nine guidelines scored >60%, among which three guidelines scored >80%. The median score for the stakeholder involvement domain was 7% (range 0–65.3%) and only two guidelines scored >60%. Nine guidelines scored 0% in this domain. The median score for the rigour of development domain was 0% (range 0–91.7%) and fourteen guidelines scored 0% in this domain. The median score for the clarity of presentation domain was 30.6% (range 13.9–91.7%) and six guidelines scored >60%, among which three guidelines scored >80%. The median score for the applicability domain was 0% (0–57.3%) and eleven guidelines scored 0% in this domain. The median score for the editorial independence domain was 0% (0–100%): four guidelines scored >80%. Discussions：Three guidelines were recommendable, and four were recommendable with modification in the stakeholder involvement, the rigour of development, and the applicability domains. Our results could contribute to improve development of future guidelines, and affect the reasonable selection and use of guidelines in clinical practice.

Background: Early extubation after cardiac surgery results in better postoperative outcomes but the optimal time for extubation remains unclear. Premature extubation may lead to unplanned reintubation that may result in adverse outcomes. The present study was undertaken to compare preoperative and operative risks and outcomes of patients with prolonged intubation >48 hours and reintubation after cardiac surgery. Aims: This is a retrospective chart review of 1259 patients who had cardiac surgery at a community hospital. After excluding patients with either operating room death, extubation <48 hours without reintubation or extubation >48 hours with reintubation, the final sample included 83 patients (6.6%) requiring reintubation after extubation in <48 hours and 100 (8.0%) with prolonged intubation without requiring reintubation. Results: Bivariate analyses revealed few statistically different preoperative and operative risks between patients with reintubation and prolonged intubation. Reintubation patients were older (p = .033) and had lower body mass index (p = .000), higher preoperative hematocrit (p = .021), and more chronic kidney disease stages >2 (p = .046) but lower odds for intra-aortic balloon pump (p = .006) and emergency surgery (p = .005). Reintubation led to worse postoperative outcomes than prolonged intubation: more acute kidney injury stage 1-3 (p = .014), coma/encephalopathy (p = .004), postoperative transfusion (p = .003), increased intensive care unit length of stay (p = .001) and hospital mortality (p = .007). Based on binary and ordinal logistic regression analyses, the differences in preoperative and operative risks were either inconsistent or trivial contributors and reintubation appears to make the largest independent contribution to poor postoperative outcomes. Conclusion: While early extubation remains the goal, patients with marginal weaning readiness may benefit from more recovery time before extubation. This study suggests that premature extubation may increase unplanned reintubation that could adversely affect postoperative outcomes after cardiac surgery.

Early detection of Hepatitis B virus (HBV) in pregnant females starts by a request of the gynecologists, which is based on their knowledge and awareness of the guidelines on conducting these tests. This is an observational cross-sectional study that investigated the gynecologists’ knowledge, attitude and practice regarding HBV during pregnancy across Jordan. A random sample of 150 gynecologists were approached, from 3 major cities in Jordan, and asked to fill a questionnaire that assessed their knowledge, attitude and practice. Statistical analysis was conducted using SPSS. One hundred and seven gynecologists have participated in the study. Most of the respondents were females, residents, and less than thirty years old. Although 97.2% of the practitioners agreed on the importance of the pregnant females on HBV, only 43% were aware of the obligatory protocol in Jordan regarding HBV screening, and only 55% would screen the pregnant females to HBV in-practice. Significant association was found between screening rates to HBV and both, level of specialty and experience of practitioners. Approximately 60% of practitioners were aware of HBV perinatal transmission risk. Only 19.6% always referred the infected pregnant females to other specialists regardless of the viral load. While 47.7% of practitioners agreed on recommending antiviral therapy for third trimester pregnant females, only 12.1% would always/often prescribe them. A noteworthy lack of Hepatitis B knowledge and screening practice among gynecologists in Jordan have been observed. A national program designed to increase the awareness of HBV testing in Jordan for both patients and gynecologists is called for.

What is precision medicine? No standard definition is found. Sometimes described as High Definition Medicine which is: “the dynamic assessment , management, and understanding of an individual’s health measured at (or near) its most basic units.” The impetus for this venture was advanced and stimulated by biogenetics, the study of how genes and their products affect health but also contribute to disease or resistance to cure. Medicine is an epistemology: a way of knowing, perceiving, remembering, finding out, proving, inferring, wondering, reflecting, a conceptual knowing relying upon observations fitted to disease concepts.

What is precision medicine? No standard definition is found. Sometimes described as High Definition Medicine which is: “the dynamic assessment , management, and understanding of an individual’s health measured at (or near) its most basic units.” The impetus for this venture was advanced and stimulated by biogenetics, the study of how genes and their products affect health but also contribute to disease or resistance to cure. Medicine is an epistemology: a way of knowing, perceiving, remembering, finding out, proving, inferring, wondering, reflecting, a conceptual knowing relying upon observations fitted to disease concepts.

Background: Prostate cancer early detection (PCa-ED) trough prostatic specific antigen (PSA) and digital rectal examination (DRE) has proved to lower mortality rates and should be carry out by primary care physicians (PCP). In Mexico, 80% of prostate cancers are detected in advanced-stages but PCP trends on PCa-ED remain unknown. Aim: To assess PCP knowledge and skills regarding PCaED. Materials and Methods: A self-administrating survey about the knowledge and skills of PCa-ED was created and delivered to PCP. Logistic regression analysis was conducted for the propensity of PCP to test prostatic specific antigen (PSA) on asymptomatic men. Results: The survey was completed by 170 PCP. The 13.5% answered being “not-well trained”. Score on risk factors knowledge was 51.5±15.7% but a score above the mean was not associated with testing PSA on asymptomatic men (p=0.674). The 40.6% answered having an institutional program on PCa-ED and 86% having access to PSA testing. Testing PSA on asymptomatic men was found in 40%. Moreover, 61.2% do not perform any digital rectal examination for PCa-ED, and this was not associated with preventing factors like lack of space, time, and assistance (p>0.05). Fewer years in practice and being a family medicine resident was associated with a less likelihood of testing PSA in asymptomatic men whereas having access to PSA testing and an institutional program on PCa-ED, increased the probability. The only significantly associated factor in the multivariable model was to have access to PSA testing [OR: 3.36 (CI 95% 1.54-7.30) p=0.002]. Conclusions: A low proportion of PCP in southeast Mexico performs PCa-ED and uses concepts outside evidence-based recommendations. A national program on PCa-ED and continuing medical education for PCP is a promising strategy to improve PCa-ED.

Abstract Rationale, aims and objectives: Sri Lanka has a well-established government-funded universal health coverage which provides free health care to all citizens. The aim of this qualitative study was to examine the out-of-pocket expenses incurred by patients with cirrhosis during admission to a tertiary care government hospital in Sri Lanka, and the impact such expenses might have on equity of care and patient outcome. Methods This is a qualitative study conducted among patients with cirrhosis admitted to a tertiary-care hospital, their caregivers and physicians. Quota sampling was used until data saturation was achieved. Data was collected through individual interviews and small group discussions using directed and open-ended questions. Thematic framework method was used to analyze data. Out-of-pocket expenses incurred by patients, its impact on equity of patient care and outcome were investigated. Results Costs for laboratory investigations, drugs purchased from the private sector and hired caretakers for hospitalized patients were reported as direct expenses. Loss of work and other sources of income were the primary indirect expenses. The impact of such expenses was higher in patients and families from lower socioeconomic categories, especially among those who were dependent on a daily income. Health care workers actively tried to minimize these out-of-pocket expenses, resulting in choice on investigations, drugs and other interventions often being made by the clinician and occasionally not being discussed with the patient, resulting in poor patient satisfaction. Conclusion This study reveals a substantial direct and indirect economic impact on patients despite being cared for in a government hospital with universal health coverage. The impact was more in patients from lower socioeconomic strata, potentially resulting in inequity in the care provided as well as the health outcomes.

The study analyzes the Italian Novel Coronavirus (2019-nCov) outbreaks, searching possible predicting model, underlining the risk of the Trend of phenomena.

Atherosclerosis is considered a systemic disease, and its presence in any site of the arterial system in the body raises suspicion of its presence somewhere else. Since atherothrombosis represents the most common cause of stroke, it is important to investigate whether coronary artery calcification, a commonly used measure of cardiac atherosclerotic burden, can be a similarly useful measure of atherosclerotic burden in the brain. This review aimed to summarize the current evidence regarding the role of CAC in the detection and prevention of cerebrovascular disease. CAC is an independent risk factor of stroke development, and using it to supplement traditional risk factors may allow better identification of higher-risk groups. Intermediate risk patients with elevated CAC scores can be started on statin therapy. CAC score may hold promise in identifying patient groups most likely to benefit from aspirin therapy. In addition, it may have a role in the identification of stroke patients who may benefit from closer cardiac monitoring as it can aid traditional scores in the detection of coronary pathology in stroke survivors.

A document by Mattia Andreoletti. Click on the document to view its contents.

Rationale, aims and objectives: Little is known about the effect of electronic audit and feedback (A&F) in primary care and its features affecting intervention effectiveness. The aim of this systematic review is: 1) to assess electronic A&F’s effectiveness in primary care and 2) to investigate facilitating factors of electronic A&F in primary care, as proposed in previous research. These factors are the use of benchmarks, frequency, cognitive load and evidence-based aspect of the feedback. Methods: The authors searched MEDLINE, Embase, CINAHL and CENTRAL from 2010 onwards by replicating the search strategy provided in the last Cochrane review on A&F. Two independent reviewers assessed the records for their eligibility, performed the data extraction and evaluated the risk of bias of the included studies using a tool provided by Cochrane. Results: Our search resulted in 8,744 records, including the 140 RCTs from the last Cochrane Review, of which 431 full-text articles were assessed for their eligibility. Twenty-nine articles were included, of which 22 studies (76%) showed an effect of the electronic A&F intervention. Of these, only 3 studies (10.5%), targeting the quality of diabetes care and the prescription of antibiotics by dentist & physicians, met all the investigated feedback features and were effective. There was a high heterogeneity in the results and the design of the A&F interventions, causing a meta-analysis to be unreliable. Conclusion: This systematic review included 29 articles describing an electronic A&F intervention in primary care, of which 22 studies (76%) showed an effect of the intervention. It was not feasible to compare the different electronic A&F interventions and their facilitating factors because they were designed and implemented very diversely. Developing a framework or methodology for automated A&F interventions in primary care could be useful for investigating future interventions although further research is necessary.