Referral writing: Consensus building on a tool for writing structured referrals

Competency in referral writing skill is needed by doctors for which they are never trained. Although there is a lot of work done about improvement of consultation letters still priority is not given. There must be a course for teaching and learning medical referral writing skills to students along with the assessment. Currently there is such tool to assess the way communication letter are written. An 18-point assessment scale has been developed through Delphi technique to increase the quality of referral letters. The objective of the present study was to design a structured Performa for writing referrals, validated by 7 participants using Delphi. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach’s alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Performa for writing referrals, with its inter-rater reliability calculated, is best for writing effective and structured referrals. The study further recommending training junior doctors in making proper referrals. MeSH Words: Referral and consultation, improving quality and referral, Checklists and referrals and consultation.

Practices of waste management in health care facilities in Nepal's Biratnagar metropolitan city

Biratnagar is a medical referral centre with tertiary health care in Eastern Nepal. The city population is 202,061, according to the 2011 census. There are 35 Health Care Facilities (HCFs) in the city as of 2014. There are 7 HCFs, 2 non-governmental HCFs, and 26 private HCFs. In 2014, the District Public Health Office Morang, the Biratnagar municipality, and the private sector collaborated to check Biratnagar's health care waste management. Investigators performed a semi-structured questionnaire and checklists while visiting health care sites. According to the survey results, 10% of HCFs use incinerators. 80% of HCFs separate their garbage, 60% use needle destroyer machines, and 50% use coloured dustbins to separate different sorts of medical waste. The bed occupancy rate is 78%. Every day, one sweeper looks for 6.66 beds. Even 10% of HCFs let their waste out in the open. HCFs do not have enough capacity for waste disposal facilities. Thus, HCFs pay the municipality Rs. 1500- 15000 a month to have the facility's waste removed. In the municipality tractor, they are hauling medical garbage and home rubbish. As a result, the city discharges health care waste with household waste in the Singhiaya River. These actions endanger public health. Biratnagar city generates 118 Kgs of hazardous health care waste daily, necessitating immediate treatment. Biratnagar Municipality should collaborate with partners to develop a short and long-term strategy.

Pleomorphic Adenoma of the Parotid Gland and the Parapharyngeal Space: Two Diametrically Opposing Surgical Philosophies for the Same Histopathologic Entity? †

Background: The aim of this study was to investigate the histopathologic findings in parotid and parapharyngeal pleomorphic adenomas and draw conclusions concerning the surgical strategy. Methods: Retrospective study of medical charts of patients with resected pleomorphic adenomas (PA) between 2005 and 2020 at two tertiary medical referral centers. Histologic specimens were reexamined by an experienced head and neck pathologist. Patients with insufficient/incomplete data were excluded from our study sample. Results: A total of 844 patients formed our study sample (291 men, 553 women, average age 48.9 years); 786 cases had a PA in the parotid gland (PG) (93.1%), and the remaining 58 cases had a PA in the parapharyngeal space (PS) (6.9%). Recurrences were detected in 8/844 cases (7/786 in the PG, 1/58 in the PS, 0.94% in total) with a mean follow-up time of 86.7 months (10–189 months) with no statistically significant differences between the study groups (p = 0.527). Our analysis showed that parapharyngeal pleomorphic adenomas are characterized by a lower incidence of an intact anatomical capsule (71.4% vs. 82.6%, p = 0.035) and a remarkably more frequent occurrence of satellite nodules (20.7% vs. 7.5%, p < 0.001). Conclusions: The more challenging histopathologic profile of parapharyngeal pleomorphic adenomas points towards the fact that parapharyngeal surgery should remain in the hands of experienced surgeons at high-volume centers.

Maternal Mortality Due to an Undiagnosed Large Thymoma in Puerperium: A Case Report

Introduction: Delayed or avoided medical care due to coronavirus disease 2019 (COVID-19) related concerns may increase morbidity and mortality associated with both acute and chronic health conditions. Thymoma is uncommon in pregnancy, although it could be accompanied with unfavorable outcomes. We report a puerperal woman presented with dyspnea and cardiac arrest with a recent diagnosis of thymoma that led to maternal mortality. Case Presentation: A 38-year-old woman with occasional dyspnea during pregnancy without medical referral was admitted to the hospital with severe dyspnea and orthopnea three days after cesarean section. Spiral computed tomography (CT) angiography showed a 64 × 84-centimeter mass with soft tissue density in the left perivascular that was originated from the anterior mediastinum; in biopsy, thymoma was suggested. She died shortly after due to severe dyspnea and cardiac arrest. Conclusions: Prenatal care during COVID-19 pandemic should not be postponed. Indeed, any symptom similar to the physiologic changes in pregnancy needs to be evaluated for optimal clinical management.

Genetic testing—whether to allow complete freedom? Direct to consumer tests versus genetic tests for medical purposes

Direct-to-consumer tests opened the opportunity of genetic testing without medical supervision, e.g., without medical referral and medical interpretation of the results. Thus, these approaches allow for free access to information concerning individual genetic profile increasing the area of personal freedom, but also posing the risk of false (positive and negative) or misinterpreted results along with health and psychological negative consequences. The paper discusses medical and non-medical applications of DTC, exploring also the legal framework implemented by European states and organizations. These legal acts strive to control the developing DTC market through such basic principles as patient protection, informed consent, medical information confidentiality, and the rights to know and to refuse knowledge about one’s genetic predispositions.

Conservative Management in Two Penetrating Fishbone Injuries: A Case Series and Literature Review

Foreign body ingestion is a regular medical referral. Patients present with different objects such as chicken bones, nails, coins, and fishbones. It is usually managed in causality and passes without any intervention. However, occasionally, we come across fishbone complications requiring intervention. We discuss the course and management of two case reports of fishbone injuries in different abdominal regions.

Safety and Efficacy of Implantation of the Bonebridge Active Transcutaneous Bone-Conduction Device Using Implant Lifts

Background Implant lifts were recently introduced to facilitate implantation of the Bonebridge and to reduce the risk of uncovering the sigmoid sinus and/or dura. Purpose The current study analyzed medical, technical, and audiological outcomes of implantation with the Bonebridge implant using lifts. Research Design This was a retrospective study on all consecutive patients implanted with a bone-conduction hearing implant at a tertiary medical referral center between March 2012 and October 2018. Outcome measures were complications, explantations, and revisions and the mean time of implant use. Audiological results were assessed as well. Outcomes were evaluated for devices implanted with BCI Lifts and compared with those implanted without lifts. Results In the study period, 13 out of a total of 54 implantations were conducted using one or two 1- to 4-mm BCI Lifts. During the follow-up period, two complications occurred and both in patients implanted without lifts (2/41; 4.9%). All patients in the lifts group were using the implant at the end of observation period. No statistically significant difference was observed in functional hearing gain or word-recognition improvement at 65 dB between two groups. Conclusions The use of BCI Lifts in Bonebridge implantations was not associated with adverse events during the observation period. The clinical follow-up revealed no complications in implantations requiring lifts. Furthermore, the functional hearing gain and the word-recognition improvement did not differ from those of devices implanted without lifts. Data indicate safety and efficacy for Bonebridge implantations using lifts.

Prevalence, Severity, and Clinical Management of Brain Incidental Findings in Healthy Young Adults: MRi-Share Cross-Sectional Study

Background and Objectives: Young adults represent an increasingly large proportion of healthy volunteers in brain imaging research, but descriptions of incidental findings (IFs) in this age group are scarce. We aimed to assess the prevalence and severity of IFs on brain MRIs of healthy young research participants aged 18–35 years, and to describe the protocol implemented to handle them.Methods: The study population comprised 1,867 participants aged 22.1 ± 2.3 years (72% women) from MRi-Share, the cross-sectional brain MRI substudy of the i-Share student cohort. IFs were flagged during the MRI quality control. We estimated the proportion of participants with IFs [any, requiring medical referral, potentially serious (PSIFs) as defined in the UK biobank]: overall, by type and severity of the final diagnosis, as well as the number of IFs.Results: 78/1,867 participants had at least one IF [4.2%, 95% Confidence Interval (CI) 3.4–5.2%]. IFs requiring medical referral (n = 38) were observed in 36/1,867 participants (1.9%, 1.4–2.7%), and represented 47.5% of the 80 IFs initially flagged. Referred IFs were retrospectively classified as PSIFs in 25/1,867 participants (1.3%, 0.9–2.0%), accounting for 68.4% of anomalies referred (26/38). The most common final diagnosis was cysts or ventricular abnormalities in all participants (9/1,867; 0.5%, 0.2–0.9%) and in those with referred IFs (9/36; 25.0%, 13.6–41.3%), while it was multiple sclerosis or radiologically isolated syndrome in participants with PSIFs (5/19; 26.3%, 11.5–49.1%) who represented 0.1% (0.0–0.4%) and 0.2% (0.03–0.5%) of all participants, respectively. Final diagnoses were considered serious in 11/1,867 participants (0.6%, 0.3–1.1%). Among participants with referred IFs, 13.9% (5/36) required active intervention, while 50.0% (18/36) were put on clinical surveillance.Conclusions: In a large brain imaging study of young healthy adults participating in research we observed a non-negligible frequency of IFs. The etiological pattern differed from what has been described in older adults.

Overseas Medical Referral: the health system challenges for Pacific Island Countries

The delivery of specialised clinical services in the small Island nations of the Pacific region is an increasing challenge in the context of a rising burden of non-communicable diseases. Resources are limited and case-loads too low to support local specialists. This article focuses on the common practice of Overseas Medical Referral (OMR), which is an increasing challenge in the region. We collected interview and secondary data across 16 Pacific Island Countries. We found that OMR policies are often weak or incomplete, systems inadequate and reforms needed. Integrating OMR fully into national health referral systems and national strategic planning and prioritisation processes is needed. There is an additional need for collection of routine data on OMR service providers in the recipient countries and the outcomes of clinical care. With these reforms, a move towards increased regional cooperation and some form of strategic purchasing is possible.

The magnitude of non-adherence and contributing factors among adult outpatient with Diabetes Mellitus in Dilla University Referral Hospital, Gedio, Ethiopia

Introduction The global prevalence of Diabetes Mellitus (DM) has increased alarmingly over the last two decades. On top of this, the issues of non-adherence to the prescribed medicines further fuel the DM- related complications to become one of the top causes of mortality and morbidity. Despite the considerable efforts in addressing the poor adherence issues, there are still plenty of problems ahead of us yet to be addressed. The objective of this study was to determine the extent of non-adherence and its contributing factors among diabetic patients attending the medical Referral clinic of Dilla University Referral Hospital. Methods The institutional-based descriptive cross-sectional study was carried out among patients with diabetes mellitus attending the medical referral clinic of Dilla University Referral Hospital. A systematic random sampling method was used to recruit study participants, and tool was adopted to assess for adherence. A pretested semi-structured questionnaire was used to collect information on factors influencing non-adherence to the diabetic medications, and in-depth interview questionnaire was used for key informant interviews for the qualitative part. Data analysis was carried out using SPSS-20. Results The overall prevalence of non-adherence to diabetic treatment regimen among the study participants was 34.0%. The study revealed that cost of transport to the hospital and taking alcohol were significantly associated with non-adherence to the diabetic treatment regimen with the (AOR = 6.252(13.56, 28.822); p < 0.000) and (AOR = 13.12(8.06, 44.73); p<0.002) respectively. Conclusions The study revealed that significant numbers of participants were non-adherent to the Diabetes Mellitus treatment regimens. Intensive counseling, and health education on the importance of good adherence and negative consequences of poor adherence need to be discussed with the patients before starting the medications, and amidst follow up.