Search Results (211)

In Italy, access to public dental care is limited, and the characteristics of patients seeking hospital-based services are poorly described. A single-centre retrospective cross-sectional study was conducted, including all individuals attending their first appointment at the public Dental Clinic of Bari University Hospital (Southern Italy) between 1 January and 31 December 2023. Demographic and clinical variables, comorbidities, reasons for consultation, and travel distance from residence were retrieved from electronic records and analysed. Among 1361 patients (49% male; mean age 47.8 ± 23.3 years), most attended for oral surgery (35%) or oral pathology (17%), while other specialties accounted for the remaining visits. Many patients presented with multiple systemic conditions, particularly cardiovascular and metabolic diseases; however, a sizeable proportion were young, apparently healthy individuals who did not meet national eligibility criteria for publicly funded dental care. The dental clinic served a wide catchment area, including referrals from other regions. Documentation on education and behavioural risk factors was frequently incomplete. Overall, these findings show that complex oral medicine and oral surgery needs are concentrated in a small number of hospital clinics and support the expansion of Italian public dental services and improvements in routine data collection. Full article

Respiratory infections represent one of the leading causes of pediatric consultations and hospitalizations in Chile, where rapid etiological identification is essential for clinical decision-making. We evaluated the impact of implementing the BIOFIRE^® SPOTFIRE^® Respiratory (R) Panel in the pediatric Emergency Department of a public referral hospital in Santiago, using a pre–post cross-sectional design comparing two winter periods (July 2023 vs. July 2024). Clinical records, laboratory data, and operational indicators were analyzed to assess changes in diagnostic yield, turnaround time, hospitalizations, discharges, supplementary test requests, and antimicrobial use. A total of 470 patients were included (224 in 2023; 246 in 2024). The etiological detection rate increased from 58.0% to 87.8% after the implementation of Spotfire^® (p < 0.0001), with marked increases in the identification of adenovirus, RSV, rhinovirus/enterovirus, and seasonal coronaviruses. Rapid molecular testing was associated with a significant rise in emergency department discharges (23.7% vs. 57.3%; p < 0.0001) and a reduction in hospitalizations (76.3% vs. 42.7%; p < 0.0001) and readmissions (9.2% vs. 0.5%; p < 0.0001). Requests for complete blood counts, chest X-rays, and antimicrobial prescriptions at discharge also decreased significantly. These effects persisted in key subgroups, including infants and children with comorbidities. In this high-demand winter setting, the BIOFIRE^® SPOTFIRE^® R Panel improved diagnostic performance and supported more efficient and targeted clinical management. Full article

Background: Type B Aortic Dissection (TBAD) management relies on risk stratification, yet evidence-based tool adoption remains inconsistent in National Health Services (NHSs). Bridging the gap between Emergency Medicine (EM) and Vascular Surgery remains essential for timely diagnosis, optimal risk stratification, and appropriate intervention to improve outcomes and reduce mortality. Methods: A cross-sectional survey of EM consultants yielded n = 173 valid responses from n = 33 units across the UK. Subgroup analyses were conducted using a Chi-square test (p < 0.05) alongside descriptive analysis. A pooled prevalence analysis of the literature, utilizing a random-effects model at a 95% confidence interval (CI), served as a benchmark for perception analysis. Agreement was evaluated using Bland–Altman analysis, incorporating upper, lower, and overall bias of agreeability. Results: Access to a rapid Computed Tomography Angiogram (CTA) was 70% (95% CI: 63.3–76.8%, p < 0.001), while 32% had standard operating procedures (SOPs) for TBAD (95% CI: 25.3–39.1%), and 26% were aware of any decision tool (95% CI: 20.6–33.6%). Labetalol as a first-line antihypertensive was more common amongst least experience (p < 0.05). TBAD diagnosis increased 1.6-fold with every 4 years of additional experience (p < 0.05). Perception analysis showed strong agreement for pain (characteristics and location), hypertension, gender, and age with moderate-to-low agreement for other factors with a reported bias of 23.58% (−38.20% to 85.36%) (p = 0.02). Conclusions: The survey suggests a degree of misperception and inconsistency in recognition of most and least prevalence factors for TBAD suspicion and management. This outcome advocates targeted strategies to enhance diagnostic accuracy using tools aligned with NHS resources and QALY frameworks. Furthermore, upon recognition of the most prevalent factors, CTA and specialist referral is advocated. Full article

Background/Objectives: Dizziness is a symptom of many disorders across a wide range of etiologies. If dizzy patients are seen for vestibular evaluation with an audiologist and no vestibular reason for the patient’s dizziness is found, the medical referral pathway can become convoluted. This can leave patients feeling discouraged and unable to manage their symptoms. Clinically symptomatic chronic respiratory alkalosis (CSCRA) is an acid–base disorder that typically presents with dizziness but is unfamiliar to practitioners in vestibular and balance care settings. Methods: In a retrospective chart review deemed exempt by the Mayo Clinic Institutional Review Board, 74 patients at Mayo Clinic Arizona were included. All had consultations with both Audiology and Aerospace Medicine to assess their dizzy symptoms. Results: After completing vestibular testing, arterial blood gas (ABG) testing, and a functional test developed at Mayo Clinic Arizona called the Capnic Challenge test, 40% of patients were found to have CSCRA contributing to their dizzy symptoms. Many of these patients also had common comorbidities of CSCRA, like postural orthostatic tachycardia syndrome (POTS), migraines, and sleep apnea. Fewer than one-fourth of these patients had measurable vestibulopathies causing their dizziness. Half of the patients referred by the vestibular audiologist to Aerospace Medicine had a diagnosis of CSCRA. Conclusions: Assessment for CSCRA should be considered as a next step for patients presenting with dizziness without a vestibular component. Being aware of the prevalence of CSCRA and its comorbidities may help balance providers offer quality interprofessional referrals and improve patient quality of life. Full article

Parents’ awareness, attitudes, and perceptions of barriers to orthodontic care for children significantly influence decisions regarding early orthodontic interventions. This mixed-methods study explored parents’ perceptions of their child’s orthodontic needs and examined their experiences and perceived barriers to accessing early orthodontic treatment (EOT) among children aged 6–12 years. Methods: Quantitative data were collected using a 12-item validated questionnaire, while qualitative insights were obtained through structured interviews and analyzed thematically. Results: Parents’ perception of their child’s orthodontic needs was significantly associated with their attitude toward seeking consultation or treatment (p < 0.001). Among parents who sought consultation, only 38.7% had initiated the required orthodontic treatment. The most frequently reported barriers were high cost (32.1%), long appointment wait times (30.6%), and lack of insurance coverage (22.5%). Thematic analysis revealed four major barriers: financial, structural, cognitive, and psychological. Conclusions: These findings highlight critical challenges to accessing EOT for children, including affordability, long waiting times, limited parental awareness, and inadequate, timely referrals. Addressing these challenges through combined efforts at both the individual and community levels could significantly enhance the uptake of early orthodontic services in children. Full article

Introduction: Palliative needs assessment and referral to advanced palliative care resources are fundamental aspects of complex chronic patients’ care. Primary care Nurse Case Managers play a key role in the care of these patients. Objective: We aimed to describe the experiences of primary care Nurse Case Managers in palliative care needs identification and complex chronic patients’ referral to advanced palliative care resources. Method: This is a qualitative descriptive study with a phenomenological approach. Semi-structured online interviews were conducted with primary care Nurse Case Managers. A thematic analysis was performed using ATLAS.ti software. Results: 20 nurses participated, 16 of whom were women, with a mean age of 52.3 years and an average of 15.9 years of experience in primary care. Regarding “Palliative care Needs Assessment”, four sub-themes have been identified: “What do you understand?”, “How do you assess?”, “Difficulties” and “Alternatives” to current palliative care needs assessment. For the “Palliative Care Referral” theme four sub-themes have been identified: “Criteria”, “Tools”, “Difficulties” and “Alternatives” for referral. Discussion: Palliative needs are identified in patients with incurable diseases when there are no curative treatment options and when quality of life must be prioritized. Symptoms, general condition, progression, and comorbidity are assessed. Open interviews and home visits are essential for assessing the social and family context and the home resources available. Barriers identified include the conspiracy of silence, limited training in non-oncological palliative care, and a lack of staff and caregiver’s understanding of illness situation. The presence of difficult symptoms and a limited life expectancy were identified as key criteria for referral to palliative care. The physician’s assessment, the family’s request, and consultation with specialized teams play a key role in prognosis. Barriers include late referrals, lack of a palliative background, inequity in access to resources, and low visibility of the palliative care needs of non-cancer patients. Conclusions: Significant challenges remain in identifying palliative needs and referral to specialized resources, highlighting the need to optimize resources, strengthen professional training, and improve coordination between levels of care to ensure quality palliative care. Full article

Background/Objectives: Teledermatology has transformed access to dermatologic care, yet its association with melanoma prognostic parameters and diagnostic pathways in tertiary settings remains incompletely characterized. To compare the clinicopathologic profile of melanomas diagnosed under face-to-face consultation (2019) versus teledermatology-based referral (teleconsultation) (2022). Methods: A retrospective observational study comparing two patient cohorts: those diagnosed with melanoma via in-person consultation in 2019, and those diagnosed through teleconsultation in 2022. These years were selected to reflect the structural shift in care delivery models before and after the COVID-19 pandemic, during which teledermatology was formally implemented. Sociodemographic, clinical, and histopathological variables were collected. A multivariable logistic regression model assessed variables associated with being diagnosed in the 2022 teledermatology cohort versus the 2019 face-to-face cohort. Statistical analyses were performed using R (v. 4.4.3). Results: A total of 151 patients were included (89 in-person in 2019, 62 via teleconsultation in 2022). Multivariable analysis identified three variables independently associated with being diagnosed via teleconsultation. Increasing Breslow thickness was inversely associated with teleconsultation diagnosis (OR 0.60 per 1 mm increase; 95% CI 0.40–0.91; p= 0.017). Similarly, the presence of histologic regression (OR 0.28; 95% CI 0.09–0.90; p = 0.032) and immunosuppression (OR 0.08; 95% CI 0.008–0.86; p = 0.037) were inversely associated with teleconsultation diagnosis. No significant associations were found for sex, age, tumor location, ulceration, mitosis, or clinical stage. Conclusions: In this retrospective single-center comparison of two care models, melanomas diagnosed through teleconsultation in 2022 were associated with a more favorable clinicopathologic profile at diagnosis than those diagnosed via face-to-face consultation in 2019. These findings support the role of teledermatology-based referral pathways in facilitating timely melanoma assessment, although causal inference is limited by the observational design. Full article

In the Netherlands, the newborn screening (NBS) program includes screening for propionic aciduria (PA) and methylmalonic aciduria (MMA). When initial screening reveals elevated C3 concentrations or abnormal ratios (C3/C2, C3/C16), a second-tier test measuring methylcitric acid (MCA) for PA and methylmalonic acid (MMA^mb) for MMA is performed. While this two-tier approach reduces false positives effectively, it can delay referral from the NBS program and diagnosis of propionic aciduria. We describe four early-onset PA cases in which the current Dutch screening algorithm negatively impacted clinical outcomes, highlighting the need for expedited referral. We investigated different alternative screening strategies to identify the most effective approach for improving timeliness, while maintaining the high specificity of Dutch PA NBS. This revised approach prioritizes the evaluation of the C3/C2 ratio in first-tier screening. Specifically, samples with a C3/C2 ratio ≥ 0.75 should be referred directly for medical consultation and confirmatory testing. For all other samples with less pronounced biochemical abnormalities, the existing two-tier screening algorithm remains an appropriate NBS protocol. To position our approach internationally, a survey of European NBS programs was conducted to compare screening and referral protocols for PA across the region. Full article

Chagas disease (CD) remains a major global health challenge and requires standardized, multidisciplinary, and evidence-based clinical approaches. This article aims to present and systematize the model of clinical routines developed at the Clinical Research Laboratory on Chagas Disease (Lapclin-Chagas), INI/Fiocruz, for the initial evaluation and longitudinal follow-up of patients with chronic CD. The proposal is intended to serve as a replicable and adaptable framework for referral centers in both endemic and non-endemic settings. Using a descriptive qualitative design, institutional protocols, national and international guidelines, and expert consultations were analyzed to construct a comprehensive care model. The resulting protocol integrates diagnostic pathways (including dual serological confirmation and clinical staging), criteria for etiological treatment, and coordinated multidisciplinary follow-up involving cardiology, gastroenterology, pharmaceutical care, nutrition, psychology, and social support. Specific pathways are also presented for Trypanosoma cruzi (T. cruzi)/HIV coinfection, laboratory accidents, and monitoring of adverse reactions to benznidazole. By consolidating more than three decades of institutional experience into operational workflows, this proposal offers an innovative contribution to the organization of CD care and provides actionable guidance for health systems seeking to improve diagnostic accuracy, therapeutic adherence, patient safety, and long-term outcomes. Full article

Background: Inequities in pain management are well documented in chronic pain and outpatient settings, yet little is known about disparities in inpatient Acute Pain Service (APS) care. This study evaluated demographic, clinical, and social factors associated with APS utilization and outcomes in an urban safety-net hospital, with a subgroup analysis of trauma patients who presented with at least three rib fractures. Methods: We performed a retrospective cohort study of two patient populations from our institution: (1) all patients receiving APS consultation from 1 January 2020 to 1 November 2022 (n = 1445) and (2) all patients with traumatic rib fractures during this time, stratified by APS consult status (n = 650). Demographics, insurance, comorbidities, opioid prescribing, and discharge outcomes were analyzed using descriptive statistics, multivariable logistic regression, and log-linear models. As APS consultation criteria were not standardized during the study period, referral patterns reflected routine clinical practice rather than predefined eligibility criteria. Results: Across the full APS cohort, patients were disproportionately represented from vulnerable groups: 30.5% were Black, 81.0% had public insurance, and 32.9% had a substance use disorder (SUD). Methadone use was a strong predictor of non-home discharge, including discharges to a medical facility, hospice, or against medical advice (AMA). In the rib fracture cohort, patients receiving APS consults had significantly higher injury severity scores (Injury Severity Score 17.1 vs. 13.0, p < 0.001). Black patients were less likely to receive APS consult (17.3% vs. 28.8%, p = 0.024). However, this association appeared to be attributable to the younger age and male predominance within this subgroup, as both factors were identified as significant predictors of APS consultation. Conclusions: APS utilization at a high-volume safety-net hospital highlights the intersection of medical vulnerability and structural inequities, with greater involvement among patients who were members of racial and ethnic minorities, publicly insured, or diagnosed with SUD. In trauma populations, younger Black men were over-represented, reinforcing the heightened injury risks Black men may face and the downstream effects on patient care. Taken together, these results highlight how APS involvement acts not only as a marker of increased injury severity but also as an intervention to improve care for vulnerable patient populations. As APS teams regularly serve these populations, they are well-positioned to bridge broader gaps through the integration of addiction and social support services, individualized pain management, and seamless coordination of care across specialties. These findings underscore the need for standardized consultation criteria and integration of social and addiction medicine resources into APS care models. Full article

Objective: This study aims to validate a referral model for specialised nursing consultation in the treatment of patients with complex wounds. Methods: A sequential mixed-methods design was used. First, a focus group with national wound care experts was conducted to identify and discuss potential referral indicators based on current clinical practice and the existing literature. The preliminary criteria were then evaluated and refined through a two-round Delphi survey involving a multidisciplinary panel of specialists. Consensus was defined as ≥70% agreement among participants. Results: Fourteen referral criteria achieved expert consensus, with several, such as the need for advanced therapies, multidisciplinary management, and the presence of peripheral vascular disease, reaching over 90% agreement. The most frequently prioritised indicators for referral included wound complexity (exposure of fascia or surgical material, presence of non-viable tissue, or associated vascular pathology) and the need for innovative advanced therapies (e.g., negative-pressure wound therapy, topical oxygen therapy). Conclusions: This validated set of referral criteria offers a structured, evidence-informed tool to support timely and appropriate referral to specialised nursing consultation, enhancing consistency, quality, and efficiency in wound management. Beyond clinical utility, these criteria may serve as a foundation for national referral policies, interprofessional collaboration, and future digital decision-support systems aimed at optimising complex wound care. Full article

Background: Primary healthcare plays a vital role in delivering pediatric services. This study aimed to examine the epidemiology of pediatric visits to a model primary healthcare (PHC) center and identify factors associated with referrals to specialized care. Methods: A retrospective chart review was conducted for all pediatric visits between January and December 2024 at a model PHC center affiliated with an academic medical city in the Kingdom of Saudi Arabia (KSA). Descriptive statistics, chi-squared tests, and multivariable logistic regression were used to assess predictors of referral. Diagnoses were categorized, and clinic types stratified to explore seasonal and diagnostic trends. Ethical approval was obtained prior to data access. Results: A total of 4520 pediatric visits were analyzed. Just over half of the patients were female, and the largest age group was school-aged children (38.1%). Visit frequency peaked in winter and spring. Most visits (78.4%) were first-time consultations, and the majority occurred in general family medicine clinics. Overall, 10.95% of visits resulted in referrals. Referrals were more common during outpatient consultations than urgent care visits and were strongly associated with specific diagnoses, particularly neurological (aOR = 11.73), eye (aOR = 8.77), ENT-related conditions (aOR = 7.73), and genitourinary or pubertal conditions (aOR = 6.60). Demographic variables such as sex and nationality were not significant predictors. Conclusions: The observed referral rate may indicate effective gatekeeping within Saudi primary care, though referral frequency alone cannot determine appropriateness. Enhancing diagnostic support and behavioral health integration could further optimize referral practices and support Vision 2030 goals for strengthened child health services. Full article

Background: The acute care surgery (ACS) model employs a 24/7 multidisciplinary team—surgeons, nurses, and residents—supported by an electronic consultation system to optimize emergency The acute care surgery (ACS) model provides 24/7 multidisciplinary management of emergency surgical patients. This study aimed to describe the demographic and clinical characteristics of patients admitted from the emergency department (ED) under general surgery, identify the most common presenting complaints and operative procedures, and determine which general surgery subspecialties were most frequently consulted at King Abdulaziz Medical City (KAMC). Methods: We conducted a retrospective study at KAMC, Riyadh (MNGHA), from September 2022 to November 2023. A total of 384 ED patients admitted under general surgery were included. Data were extracted from the BestCare electronic medical record and analyzed for demographics, presenting complaints, operative procedures, and subspecialty consultations. Results: Of 384 patients, 204 (53.1%) were male and 180 (46.9%) were female. The largest age group was 30–45 years (n = 112, 29.2%), followed by <30 years (n = 98, 25.5%). Leading presenting complaints were abdominal pain (n = 243, 63.3%), fever with nausea/vomiting (n = 68, 17.7%), and rectal pain/bleeding (n = 44, 11.5%). Laparoscopic cholecystectomy was the most common procedure (n = 123, 32.0%), followed by laparoscopic appendectomy (n = 57, 14.8%). ACS received most consultations (n = 231, 61.8%), with additional referrals to colorectal surgery (n = 86, 23.0%) and upper gastrointestinal surgery (n = 40, 10.7%). Nearly all consult requests originated in the ED (n = 355, 98.9%). Conclusions: Abdominal pain was the predominant ED complaint prompting surgical referral, and laparoscopic cholecystectomy and appendectomy were the most frequently performed procedures. ACS was the primary subspecialty consulted, underscoring its central role in emergency surgical care at KAMC. Full article

Background: The COVID-19 pandemic profoundly disrupted healthcare systems worldwide, compelling rapid adaptation of clinical workflows and accelerating the integration of telemedicine. Objective: This study evaluates the implementation of telemedicine in neurosurgical outpatient care at a tertiary referral hospital in Madrid during the first epidemic wave (March–May 2020) and explores its long-term significance five years later. Methods: A retrospective observational analysis including 5175 neurosurgical outpatient consultations was conducted, comparing the first epidemic wave of COVID-19 (2070 teleconsultations) with the equivalent period in 2019 (3105 in-person visits). Demographic, clinical, and procedural data were analyzed, including six-month follow-up outcomes. Univariate and multivariate analyses were performed to identify factors associated with teleconsultation use and follow-up delay. Results: The total number of consultations decreased by 33% compared to the pre-pandemic year. In May 2020, teleconsultations represented more than 70% of all visits. Continuity of care was preserved (follow-up adherence >80%), and missed appointments declined to zero. Cranial and oncological pathologies were prioritized, while degenerative and benign cases were largely deferred. Teleconsultation independently predicted delayed six-month follow-up (aOR 1.9, 95% CI 1.3–2.8, p = 0.002) and a lower likelihood of surgical indication (aOR 0.4, 95% CI 0.2–0.7, p = 0.004). Despite these differences, remote care ensured accessibility, safety, and clinical continuity under extreme healthcare system strain. Five years perspective: In addition to these early outcomes, the study describes the sustained integration of telemedicine during the subsequent five years, illustrating how this model became permanently embedded in routine neurosurgical practice in this center. Conclusions: This study represents one of the earliest structured telemedicine experiences in Spanish neurosurgery. The rapid adaptation of the Hospital General Universitario Gregorio Marañón ensured care continuity during the pandemic and catalyzed the lasting adoption of hybrid models that enhance accessibility, safety, efficiency, and healthcare system resilience. Full article

Background: Population aging in Poland has led to rising healthcare needs, but comprehensive evidence on long-term utilization patterns is limited. This study aimed to analyze healthcare use and disease burden among older adults, with particular focus on the impact of the COVID-19 pandemic, including its effects on care pathways, continuity of services, and differences between urban and rural populations. Methods: We conducted a retrospective study using anonymized medical records from a primary healthcare network in Poland between January 2020 and December 2024. The sample included 42,844 patients aged 60 years or older patients aged ≥60 years, with a total of 738,300 consultations. Data on demographics, visit type, prescriptions, referrals, diagnostic tests, and follow up were analyzed using chi-square tests, logistic regression, and nonparametric comparisons. Results: The mean age of patients was 77.5 years (SD 9.4), and 63.7% were women. The mean number of visits in the preceding 12 months was 10.3 (range 0–460). Prescriptions were issued in 56.9% of visits, referrals in 33.5%, and diagnostic tests in 21.4%. Patients with chronic diseases were more likely to receive diagnostic tests than those without (32.4% vs. 21.1%, χ² = 1570.42, p < 0.0001), but less likely to return within 30 days (23.4% vs. 39.4%, χ² = 2243.76, p < 0.0001). First visits generated more referrals than follow ups (41.6% vs. 32.9%, χ² = 1620.51, p < 0.0001). Completed visits were strongly associated with prescription issuance (63.2% vs. 16.4%, χ² = 1048.76, p < 0.0001). Return analyses showed that patients with more prior visits were significantly more likely to re-engage at 30, 60, and 90 days (all p < 0.0001). Age correlated positively with total number of visits (ρ = 0.136, p < 0.05) with the oldest adults more likely to return at 60 and 90 days. Visit realization decreased during early pandemic phases but increased significantly post-COVID (OR = 1.76, p < 0.001). Psychiatric referrals increased the odds of return within 30 days (OR = 1.42) and 60 days (OR = 1.36). Conclusions: Older adults in Poland demonstrate high healthcare utilization, with patterns shaped by age, chronic disease status, and pandemic-related disruptions. While statistical associations were robust, effect sizes were small, highlighting the need to focus on clinically meaningful differences in planning geriatric care. The findings highlight that COVID-19 acted as a major modifying factor of healthcare engagement, revealing the vulnerability of geriatric care continuity to system-level disruptions. Full article