Specialist Referral and Outcomes in Adolescent Athletes With Prior Concussion History

ObjectiveTo examine specialist referral patterns and clinical outcomes in adolescents with differing levels of prior concussion history.BackgroundLimited evidence exists on healthcare utilization and outcomes in concussed adolescent athletes with and without a history of prior concussion.Design/MethodsData were prospectively collected from participants aged 12–18 diagnosed with a sport-related concussion and documented prior concussion history between August 2015-March 2020. Participants were separated into 3 groups: 0, 1, and 2 + prior concussions. Demographics, medical history, specialist referrals, and clinical outcome variables obtained at 3-months post-concussion were analyzed.ResultsOne thousand one hundred ninety-seven participants were included: 114 (10.4%) had 2+, 213 (19.4%) had 1, and 770 (70.2%) had 0 prior concussions. There was no difference in sex or time to presentation. A small difference was found across age (15.3 ± 1.6 vs 14.9 ± 1.6 vs 14.5 ± 1.6 years, p < 0.001). Significant differences were also observed between groups in self-reported history of psychological disorders (14.9 vs 15 vs 8.4%, p = 0.01) and headaches/migraines (25.4 vs 20.2 vs 15.5%, p = 0.02). Significant differences between the groups were found in specialist referrals, with more referrals made in the 2 + group to physical therapy (39.6 vs 28.2 vs 23.4%, p = 0.001), neuropsychology (17.1 vs 5.3 vs 7.5%, p = 0.001), and neurology (8.9 vs 2.9 vs 2.2%, p = 0.001). Fewer participants in the 2 + group recovered in = 30 days (53.6 vs 65.6 vs 68.5%, p = 0.04) and reported lower rates of return to activity at 3-months post-concussion (67.9 vs 85.9 vs 87.6%, p < 0.001). No differences were seen in symptom severity, PHQ-8, or GAD-7 scores. All reported as 2 + vs 1 vs 0.ConclusionsConcussed adolescent athletes with a history of 2 or more prior concussions had a higher rate of specialist referrals, were less likely to have returned to prior level of play/activity 3 months following injury, and were less likely to have resolution of symptoms in 30 days or less.

Smart Homes as Enablers for Depression Pre-Diagnosis Using PHQ-9 on HMI through Fuzzy Logic Decision System

Depression is a common mental illness characterized by sadness, lack of interest, or pleasure. According to the DSM-5, there are nine symptoms, from which an individual must present 4 or 5 in the last two weeks to fulfill the diagnosis criteria of depression. Nevertheless, the common methods that health care professionals use to assess and monitor depression symptoms are face-to-face questionnaires leading to time-consuming or expensive methods. On the other hand, smart homes can monitor householders’ health through smart devices such as smartphones, wearables, cameras, or voice assistants connected to the home. Although the depression disorders at smart homes are commonly oriented to the senior sector, depression affects all of us. Therefore, even though an expert needs to diagnose the depression disorder, questionnaires as the PHQ-9 help spot any depressive symptomatology as a pre-diagnosis. Thus, this paper proposes a three-step framework; the first step assesses the nine questions to the end-user through ALEXA or a gamified HMI. Then, a fuzzy logic decision system considers three actions based on the nine responses. Finally, the last step considers these three actions: continue monitoring through Alexa and the HMI, suggest specialist referral, and mandatory specialist referral.

Flexible Nasal Endoscopic Procedures in Family Medicine: Indications and Effectiveness

Background and Objectives: Most literature about flexible nasolaryngoscopy comes from specialty clinics, making it unclear if these indications can be effectively managed without referral. This study evaluated effectiveness of diagnosis and management of upper airway complaints, utilizing flexible nasal endoscopic procedures, in a family medicine center. Methods: We performed retrospective chart review for all patients who had nasal endoscopy, nasopharyngoscopy, and nasolaryngoscopy performed at the University of Florida Family Medicine Center over 3 years (n=89) with 5 additional years of follow up. We used descriptive statistics to evaluate indications, diagnoses, effectiveness of management by family medicine, and referral rate. Results: The most common primary indications were hoarseness (n=33, 37%), chronic cough (n=20, 22%), nasal obstruction (n=9, 10%), and unilateral ear dysfunction (n=6, 7%). The most common primary diagnoses found were allergic rhinitis/postnasal drip (n=41, 46%), laryngopharyngeal reflux (LPR)/gastroesophageal reflux disease (GERD; n=24, 27%), masses concerning for malignancy (n=4, 4.5%), true vocal cord (TVC) polyp (n=3, 3%), TVC nodules (n=3, 3%), and epistaxis (n=3, 3%). Of the four concerning masses, two were confirmed cancers (2%). In addition, there was one case (1%) of erythroleukoplakia with dysplasia of the TVC. Most patients had documented improvement with family medicine management (n=57, 64%) and another six (7%) had follow up without documentation of status and no need for referral. Thus, a total of 71% (n=64) did not require referral and 20% (n=18) needed specialist referral. Conclusions: Flexible nasal endoscopic procedures are effective in the care of patients in a family medicine residency center and can be safely performed and taught to residents.

Diagnosing COPD in general practice

COPD prevalence is likely to be underestimated in the UK. Anne Rodman explores the current evidence base for diagnosing COPD Chronic obstructive pulmonary disease (COPD) is an umbrella term for several different pathological processes in the lungs of susceptible individuals. COPD should be considered in any patient who has symptoms and a history of exposure to risk factors for the disease. The cornerstone of COPD diagnosis is to identify risk factors for this preventable condition, recognise and investigate any symptoms that are not commonly found in COPD, and confirm that obstruction is present with correctly performed and interpreted spirometry. This article explores the current evidence base for diagnosing COPD, how to differentiate it from asthma and other conditions with similar symptoms, and the rationale for specialist referral.

Post-COVID-19 assessment in a specialist clinical service: a 12-month, single-centre, prospective study in 1325 individuals

IntroductionPost-COVID-19 complications require simultaneous characterisation and management to plan policy and health system responses. We describe the 12-month experience of the first UK dedicated post-COVID-19 clinical service to include hospitalised and non-hospitalised patients.MethodsIn a single-centre, observational analysis, we report the demographics, symptoms, comorbidities, investigations, treatments, functional recovery, specialist referral and rehabilitation of 1325 individuals assessed at the University College London Hospitals post-COVID-19 service between April 2020 and April 2021, comparing by referral route: posthospitalised (PH), non-hospitalised (NH) and post emergency department (PED). Symptoms associated with poor recovery or inability to return to work full time were assessed using multivariable logistic regression.Results1325 individuals were assessed (PH: 547, 41.3%; PED: 212, 16%; NH: 566, 42.7%). Compared with the PH and PED groups, the NH group were younger (median 44.6 (35.6–52.8) years vs 58.3 (47.0–67.7) years and 48.5 (39.4–55.7) years), more likely to be female (68.2%, 43.0% and 59.9%), less likely to be of ethnic minority (30.9%, 52.7% and 41.0%) or seen later after symptom onset (median (IQR): 194 (118–298) days, 69 (51–111) days and 76 (55–128) days; all p<0.0001). All groups had similar rates of onward specialist referral (NH 18.7%, PH 16.1% and PED 18.9%, p=0.452) and were more likely to require support for breathlessness (23.7%, 5.5% and 15.1%, p<0.001) and fatigue (17.8%, 4.8% and 8.0%, p<0.001). Hospitalised patients had higher rates of pulmonary emboli, persistent lung interstitial abnormalities and other organ impairment. 716 (54.0%) individuals reported <75% optimal health (median 70%, IQR 55%–85%). Less than half of employed individuals could return to work full time at first assessment.ConclusionPost-COVID-19 symptoms were significant in PH and NH patients, with significant ongoing healthcare needs and utilisation. Trials of interventions and patient-centred pathways for diagnostic and treatment approaches are urgently required.

Autochthonous North American Leprosy: A Second Case in Canada

Autochthonous leprosy was reported in the Southern USA in 2011 and has comprised an average of 34% of new cases from 2015 to 2020 in that country. We report a similar case in a patient from Western Canada. A 50-year old male patient presented with a four-year history of a chronic rash. Pathology stains revealed acid-fast bacilli prompting specialist referral. Examination was suspicious for leprosy, which was confirmed on slit skin smears and molecular testing. The patient responded well to treatment. Genotypic testing mapped the organism to the 3I-2 SNP type, which is of European origin and is the type found in implicated armadillo species in North America.

P038 Insomnia - Going backward to go forward

Background Although there are common features in people with insomnia, for each individual there are possible different contributing factors and pathophysiological processes; each needing specific tailoring of treatment. We aim to understand treatments undertaken prior to specialist referral, common features on presentation and contributing factors in individual cases identified as part of their assessment. Methods We will undertake a retrospective audit of consecutive patients presenting with insomnia to a single private practice with a high insomnia case-load. We are collecting demographic data, details of prior and current treatments, clinical characteristics at presentation, outcomes of investigations and classification insomnia sub-type using the International Classification of Sleep Disorders-2 (ICSD-2). Data will be descriptive to allow understanding of the type and nature of patients presenting with insomnia and a deconstruction of contributing factors to the presenting problem of insomnia. Progress to date Low-risk ethics approval submitted via St Vincent’s Human Research Ethics Committee. Literature review in progress. Intended outcome and impact The umbrella term “insomnia” belies its heterogeneity. Although there are common factors in most insomnia presentations, recognised in the simplification of diagnostic criteria in ICSD-3 and DSM 5, in managing individual patients it is also important to understand characteristics that are particular to the person. Whilst generic cognitive behavioural therapy for insomnia (CBTi) has been proven to be effective, in expert hands the response rate is still in the region of 60%, potentially reflecting a role for more tailored treatments for individuals to complement CBTi.

EP.TH.5Online application for self-referral of the patients with breast symptoms

Introduction The study aimed to devise a self-referral mobile/web application for patients with new breast symptoms, giving them an outcome, thus bypassing the need for primary care consultation. Methods The online application was designed on the automated algorithm based on evidence-based guidelines for referral to breast onco-plastic units. A retrospective questionnaire-based anonymous survey was carried out at the breast unit in Southend University Hospital (January 2019 to March 2020). The outcome of the patients was recorded, the same data was entered in the software and its outcome was compared with their clinic outcome to assess and validate the software. Chi-square and t test were used in formulating results. Results Data was collected for 366 patients who were referred urgently to the clinic. Only 50.5% (n = 186) were appropriately referred, with the main complaint being breast lump (94.1%). 39.6% of referred patients did not require a secondary care referral. Sensitivity and specificity for identifying patients requiring urgent referral was 100% and 98%, respectively. Conclusion A significant number of urgent referrals to breast units do not require urgent specialist referral, and this results in a big strain on the hospital service. The discussed self-referral pathway is a promising alternative with the potential to reduce workload in primary and secondary care and improve patient satisfaction.

Comparison of Palliative Care Models in Idiopathic Pulmonary Fibrosis

Introduction: Palliative care (PC) is recommended in idiopathic pulmonary fibrosis (IPF) patients but poorly implemented. Integration of PC into routine management by pulmonologists may improve overall and end-of-life (EOL) care, but the optimal model of PC delivery is unknown. Objective: To describe three PC care delivery models and their impact on EOL; the Multidisciplinary Collaborative ILD clinic, Edmonton, Canada (EC) and the Bristol ILD Service, UK (BC) that provide primary level PC; and the Queen’s University ILD Clinic, Kingston, Canada (QC), which refers IPF patients to a specialist PC Clinic using specific referral criteria. Methods: A multicenter retrospective observational study of IPF patients receiving care in the identified clinics (2012–2018) was designed. Demographics; PC delivery, including symptom management; advance care planning (ACP); and location of death data were examined. Results: 298 IPF patients were included (EC 95, BC 84, and QC 119). Median age was 71 years with 74% males. Overall, 63% (188) patients received PC. Primary PC approach in EC and BC led to more patients receiving PC (98% EC, 94% BC and 13% QC (p < 0.001/<0.001)) with earlier initiation compared to QC. Associated higher rates of non-pharmacologic dyspnea management [98% EC, 94% BC, and 2% QC (p < 0.001/<0.001); opioids (45% EC and BC, and 23% QC (p < 0.001/<0.001)); and ACP (100% EC and BC, and 13% QC patients (p < 0.001/<0.001))] were observed. Median follow up (IQR) was 16 months (5–28) with 122 deaths (41%). Primary PC model in EC and BC decedents was associated with more PC delivery (91% EC, 92% BC and 19% QC (p < 0.001)) with more symptoms management, oxygen, and opiate use than QC (p < 0.001; p = 0.04; p = 0.01). EOL discussions occurred in 73% EC, 63% BC, and 4% QC decedents (p = 0.001). Fifty-nine% (57) died at home or hospice and 38% (36) in hospitals. Concordance rate between preferred and actual location of death was 58% in EC (0.29 (−0.02–0.51)) and 37% in BC models (−0.11 (−0.20–0.15)). Conclusions: Primary PC approach for IPF is feasible in ILD clinics with concurrent disease management and can improve access to symptom management, ACP, PC and EOL care. Reliance on PC specialist referral for PC initiation outside of the ILD clinic can result in delayed care.