Characteristics of general practitioner referrals to podiatrists in Australia, 2000-2016

OBJECTIVE

The aim of the study was to describe patterns of referral to podiatrists by general practitioners (GPs) in Australia.

STUDY DESIGN

This is a continuous cross-sectional study of Australian general practice activity.

METHODS

We analysed data from the Bettering the Evaluation and Care of Health program, collected from April 2000 to March 2016 inclusive. Data were summarised using descriptive statistics with 95% confidence intervals around point estimates. Multivariate logistic regression was used to identify GP and patient characteristics independently associated with referral.

RESULTS

The data set included 1,568,100 encounters, including 5,912 podiatry referrals. Referrals increased from 7.0 to 39.5 per 1000 population over the evaluation period. In multivariate analyses, female GPs were more likely than male GPs to refer, and GPs aged ≥55 years were less likely to refer. Patients referred to podiatrists were more likely to be aged ≥85 years, be Indigenous, be from an English-speaking background and have previously been seen at the practice. The problem generating the highest number of referrals was diabetes. After the introduction of Medicare funding, referred patients were more likely to be women, be aged >45 years, have a healthcare card, be socio-economically disadvantaged and have previously been seen at the practice.

CONCLUSIONS

GP referral to podiatrists in Australia increased markedly after the introduction of Medicare funding and appears to be targeted to those with the greatest need. Further research is required to determine whether this policy has improved outcomes and is cost-effective.

Cause for Concern: Behavioral and Psychological Symptoms of Dementia in Delaware's Long-Term Care Facilities

INTRODUCTION

Much of the suffering and expense associated with treatment of persons with dementia (Major Neurocognitive Disorder) arises from associated noncognitive behavioral and psychological symptoms of dementia (BPSD). Although a consensus on the prevalence of BPSD is lacking, evidence suggests that most people with dementia will manifest one or more of these symptoms during the disorder's progression. BPSD raise the cost of care by leading to more frequent emergency room visits, more and longer hospitalizations, and earlier admission to long-term care facilities (LTCF). Treatment of BPSD presents a stressful challenge in LTCFs. We sought to investigate the care burden of BPSD in Delaware's LTCFs and to gather data that can inform management approaches.

METHODS

Using REDCap, we created an anonymous cross-sectional survey designed for completion by LTCF administrators. The Delaware Health Care Facilities Association (DHCFA) and Delaware's Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) encouraged participation. A link to the survey was emailed to the administrators of 81 facilities in Delaware. The resulting data were evaluated using descriptive statistics.

RESULTS

Forty-four of the 81 facilities surveyed opened the survey link. Thirty-eight facilities answered at least some of the questions, and 19 surveys were fully completed. The reported average prevalence of BPSD among Delaware LTCF residents with dementia was 49.3% (SD 28.9). The five most frequently reported BPSD symptoms were anxiety, agitation, wandering, dysphoria/depression, and appetite/eating abnormalities. All facilities reported employing a spectrum of pharmacologic and non-pharmacologic management strategies. Twenty-two of 24 respondents (91.7%) reported that behavioral health consultation was available at their facilities and 18 of 20 respondents (90.0%) indicated that they provided training on how to manage residents with BPSD.

CONCLUSION

BPSD are a pervasive concern among Delaware's LTCFs. LTCFs may benefit from the development of training programs and dissemination of treatment guidelines incorporating evidence-based interventions and their implementation in managing BPSD to improve care, decrease stress on residents and caregivers, and reduce some avoidable health care costs.

Isolation and characterization of vibriophage vB_Vc_SrVc9: an effective agent in preventing Vibrio campbellii infections in brine shrimp nauplii (Artemia franciscana)

AIMS

This study describes the physicochemical and genomic characterization of phage vB_Vc_SrVc9 and its potential for phage therapy application against a pathogenic Vibrio campbellii strain.

METHODS AND RESULTS

A lytic phage vB_Vc_SrVc9 against V. campbellii was isolated from shrimp farm sediment, and characterized physicochemical and genomically. The use of vB_Vc_SrVc9 phage increased the survival in brine shrimp Artemia franciscana and reduced presumptive V. campbellii to nondetectable numbers. Genomic analysis showed a genome with a single contig of 43·15 kb, with 49 predicted genes and no tRNAs, capable of recognizing and generating complete inhibition zones of three Vibrio sp.

CONCLUSIONS

To our knowledge vB_Vc_SrVc9 is a lytic phage that could be used against Vibrio infections, reducing vibrio presence without any apparent impact over the natural microbiota at the family level in 28 libraries tested.

SIGNIFICANCE AND IMPACT OF THE STUDY

vB_Vc_SrVC9 is a novel phage and ecofriendly alternative for therapeutic applications and biotechnological purposes because is stable at different environmental conditions, has the potential to eliminate several strains, and has a short latent period with a good burst size. Therefore, the use of phages, which are natural killers of bacteria, represents a promising strategy to reduce the mortality of farmed organisms caused by pathogenic bacteria.

Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions

STUDY QUESTION

What are appraisals, coping strategies and emotional reactions of patients to coronavirus disease 2019 (COVID-19) fertility clinic closures?

SUMMARY ANSWER

Clinic closure was appraised as stressful due to uncertainty and threat to the attainability of the parenthood goal but patients were able to cope using strategies that fit the uncertainty of the situation.

WHAT IS KNOWN ALREADY

Psychological research on COVID-19 suggests that people are more anxious than historical norms and moderately to extremely upset about fertility treatment cancellation owing to COVID-19.

STUDY DESIGN, SIZE, DURATION

The study was of cross-sectional design, comprising a mixed-methods, English language, anonymous, online survey posted from April 09 to April 21 to social media. Eligibility criteria were being affected by COVID-19 fertility clinic closure, 18 years of age or older and able to complete the survey in English. In total, 946 people clicked on the survey link, 76 did not consent, 420 started but did not complete survey, and 450 completed (48% completion, 446 women, four men).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall 74.7% (n = 336) of respondents were residents in the UK with an average age of 33.6 years (SD = 4.4) and average years trying to conceive, 3.5 years (SD = 2.22). The survey comprised quantitative questions about the intensity of cognitive appraisals and emotions about clinic closure, and ability to cope with clinic closure. Open-text questions covered their understanding of COVID-19 and its effect on reproductive health and fertility plans, concerns and perceived benefits of clinic closure, and knowledge about closure. Sociodemographic information was collected. Descriptive and inferential statistics were used on quantitative data. Thematic qualitative analysis (inductive coding) was performed on the textual data from each question. Deductive coding grouped themes from each question into meta-themes related to cognitive stress and coping theory.

MAIN RESULTS AND THE ROLE OF CHANCE

Most patients (81.6%, n = 367) had tests or treatments postponed, with these being self (41.3%, n = 186) or publicly (46.4%, n = 209) funded. Patients appraised fertility clinic closure as having potential for a more negative than positive impact on their lives, and to be very or extremely uncontrollable and stressful (p ≤ .001). Most reported a slight to moderate ability to cope with closure. Data saturation was achieved with all open-text questions, with 33 broad themes identified and four meta-themes linked to components of the cognitive stress and coping theory. First, participants understood clinic closure was precautionary due to unknown effects of COVID-19 but some felt clinic closure was unfair relative to advice about getting pregnant given to the public. Second, closure was appraised as a threat to attainability of the parenthood goal largely due to uncertainty of the situation (e.g., re-opening, effect of delay) and intensification of pre-existing hardships of fertility problems (e.g., long time waiting for treatment, history of failed treatment). Third, closure taxed personal coping resources but most were able to cope using thought-management (e.g., distraction, focusing on positives), getting mentally and physically fit for next treatments, strengthening their social network, and keeping up-to-date. Finally, participants reported more negative than positive emotions (p ≤  .001) and almost all participants reported stress, worry and frustration at the situation, while some expressed anger and resentment at the unfairness of the situation. Overall, 11.9% were not at all able to cope, with reports of intense feelings of hopelessness and deteriorating wellbeing and mental health.

LIMITATIONS, REASONS FOR CAUTION

The survey captures patient reactions at a specific point in time, during lockdown and before clinics announced re-opening. Participants were self-selected (e.g., UK residents, women, 48% starting but not completing the survey), which may affect generalisability.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility stakeholders (e.g., clinics, patient support groups, regulators, professional societies) need to work together to address the great uncertainty from COVID-19. This goal can be met proactively by setting up transparent processes for COVID-19 eventualities and signposting to information and coping resources. Future psychological research priorities should be on identifying patients at risk of distress with standardised measures and developing digital technologies appropriate for the realities of fertility care under COVID-19.

STUDY FUNDING/COMPETING INTEREST(S)

University funded research. Outside of the submitted work, Professor Boivin reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S; grants from Merck Serono Ltd; and that she is co-developer of the Fertility Quality of Life (FertiQoL) and MediEmo apps. Outside of the submitted work, Dr. Mathur reports personal or consultancy fees from Manchester Fertility, Gedeon Richter, Ferring and Merck. Outside of the submitted work, Dr. Gameiro reports consultancy fees from Ferring Pharmaceuticals A/S, Access Fertility and SONA-Pharm LLC, and grants from Merck Serono Ltd. The other authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A

Validation of a 2-Item Food Insecurity Screen Among Adult General Medicine Outpatients

Food insecurity is defined as limited access to food and is associated with adverse physical, social, and emotional health outcomes. As social needs are addressed in heath care, efficient methods to identify patients living in food insecure households are necessary. A 2-item screen (HFSS-2) derived from the US Department of Agriculture Household Food Security Scale (HFSS-18) has been validated among parents of pediatric patients with a sensitivity of 97% and specificity of 83%. The objective was to validate the HFSS-2 in adult general medicine outpatients. HFSS-18 was administered to a sample of adult general medicine outpatients in Delaware from 2018 to 2019. The authors evaluated the sensitivity and specificity of the HFSS-2. Multivariable logistic regression was used to calculate convergent validity between the HFSS-18 and the HFSS-2. Three hundred ninety patients were approached with 295 (75%) enrolling in this study; 17.6% (52/295) were food insecure. A confirmatory response to either of the 2 items from the HFSS-2 had a sensitivity of 98% (95% CI: 94%, 100%) and specificity of 91% (95% CI: 87%, 94%). Food insecurity was associated with increased odds of coronary heart disease (adjusted odds ratio [AOR] 4.63; 95% CI: 1.55, 13.79; AOR 4.19; 95% CI: 1.51, 11.59) and diabetes (AOR 4.19; 95% CI: 1.94, 9.08; AOR 3.73; 95% CI: 1.83, 7.92) using both the HFSS-18 and the HFSS-2. HFSS-2 was found to be highly sensitive and specific. This is the first study to validate this tool in this population that the authors are aware of.

Examining the relationship between food environment and gestational diabetes

BACKGROUND

Studies have shown an association between the incidence of gestational diabetes and living in neighborhoods oversaturated with unhealthy foods.

OBJECTIVE

This study sought to determine if the food environment also affects the management of gestational diabetes. We hypothesized that living in areas with a higher quality of food decreased the risk of requiring medication to treat gestational diabetes.

STUDY DESIGN

This was a retrospective cohort study of singleton births at the Christiana Care Health System between 2015 and 2018. Patients with gestational diabetes who live in Delaware (N=1327) were geocoded and classified according to their census tract food environment. The food environment was assessed using the modified Retail Food Environment Index, which measures the percentage of healthy food retailers among all food retailers within a half-mile radius of the census tract boundaries. The modified Retail Food Environment Index scores were divided into 3 categories: poor (modified Retail Food Environment Index score, 0-3), average (modified Retail Food Environment Index score, 4-10), and good or above average (modified Retail Food Environment Index score, ≥11) food environments. The primary outcome was the prevalence of A2 gestational diabetes mellitus. Several neonatal and obstetrical outcomes were also examined including type II diabetes mellitus (defined as a 2-hour glucose tolerance test with at least 1 value above the threshold), cesarean delivery, shoulder dystocia, admission to the neonatal intensive care unit, neonatal hypoglycemia, neonatal hyperbilirubinemia, neonatal respiratory distress syndrome, and macrosomia.

RESULTS

A total of 689 (52%) women were diagnosed as having A2 gestational diabetes mellitus. Women in the average or good or above average food environment groups had a lower prevalence of A2 gestational diabetes mellitus than women in the poor food environment group (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.92] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.56; 95% confidence interval, 0.40-0.82]). They also had a lower prevalence of type II diabetes mellitus (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.25; 95% confidence interval, 0.09-0.72] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.48; 95% confidence interval, 0.27-0.86]). There were no differences in the other secondary outcomes of interest.

CONCLUSION

The food environment affects the requirement for medication to obtain glycemic levels that are within the target range for those with gestational diabetes.

A fast technique to measure the dewpoint pressure of a retrograde condensate gas using a microfluidic volume

A new method to determine the dewpoint pressure of a retrograde condensate from a fast, non-equilibrium measurement performed in a microfluidic optical cell is presented. The inflection point of the optical transmission recorded during depressurization agrees well with the dewpoint pressure of the sample, determined by conventional laboratory techniques. With this new technique, a measurement can be performed in less than 5 min and requires far less than a milliliter of the sample. Benchmarking of this technique is presented using four retrograde condensate samples, which were created in the laboratory using multi-component compositions that are based on oilfield samples. Each sample was characterized at three different temperatures, and their maximum relative liquid volumes (maximum liquid volume/total system volume at the dewpoint pressure) ranged from 1.3% to 13.5% for these temperatures. The dewpoint pressure measured by this technique differs by no more than 100 psi from that measured in a conventional laboratory for samples of a richness of 4% or higher, while leaner samples display a difference of ∼200 psi.

An experimental evaluation of the benefits and costs of providing fertility information to adolescents and emerging adults

STUDY QUESTION

Does the provision of fertility (compared to control) information affect fertility-related knowledge, perceived threat of infertility, anxiety, physical stress and fertility plans in adolescents and emerging adults?

SUMMARY ANSWER

The provision of fertility information was associated with increased fertility knowledge (emerging adults) and greater infertility threat (adolescents and emerging adults).

WHAT IS KNOWN ALREADY

According to fertility education research, adolescents and emerging adults know less than they should know about fertility topics. Fertility knowledge can be improved through the provision of information in older adults.

STUDY DESIGN, SIZE, DURATION

Experimental design. Secondary and university students completed pre-information questionnaires, were randomly assigned via computer to an experimental group, read either fertility (FertiEduc group) or healthy pregnancy information (Control group), and completed post-information questionnaires. Data were collected in group sessions via an online portal.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible participants were aged 16–18 (adolescents) or 21–24 years (emerging adults), childless, not currently pregnant (for men, partner not pregnant) or trying to conceive, presumed fertile and intending to have a child in the future. Of the 255 invited, 208 (n = 93 adolescents, n = 115 emerging adults) participated. The FertiEduc group received ‘A Guide to Fertility’, four online pages of information about fertility topics (e.g. ‘When are men and women most fertile?’) and the Control group received four online pages from the National Health Service (NHS) pregnancy booklet ‘Baby Bump and Beyond’. Participants completed a questionnaire (fertility knowledge, perceived threat of infertility, anxiety, physical stress and fertility plans, moderators) prior to and after the provision of information. Mixed factorial analysis of variance was used to examine the effects of information provision and hierarchical multiple regression to assess potential moderators of knowledge.

MAIN RESULTS AND THE ROLE OF CHANCE

The FertiEduc and Control groups were equivalent on age, gender, disability, relationship status and orientation at baseline. Results showed that fertility information significantly increased fertility knowledge for emerging adults only (P < 0.001) and threat of infertility for emerging adults and adolescents (P = 0.05). The moderators were not significant. Participation in the study was associated with an increase in feelings of anxiety but a decrease in physical stress reactions. Adolescents had more optimal fertility plans compared to emerging adults due to being younger.

LIMITATIONS, REASONS FOR CAUTION

This was an experimental study on a self-selected sample of men and women from selected educational institutions and only short term effects of information were studied.

WIDER IMPLICATIONS OF THE FINDINGS

Provision of fertility information can have benefits (increased fertility knowledge) but also costs (increase potential threat of infertility). Adolescents find fertility information positive but do not learn from it. Fertility education should be tailored according to age groups and created to minimise negative effects. Longitudinal examination of the effects of fertility information in multi-centre studies is warranted and should include measures of perceived threat of infertility.

STUDY FUNDING/COMPETING INTEREST(S)

Cardiff University funded this research. All authors have no conflicts of interest to declare.

Management of foot/ankle osteoarthritis by Australian general practitioners: an analysis of national patient-encounter records

OBJECTIVE

To document the management of foot/ankle osteoarthritis/arthritis (OA) by general practitioners (GP) in Australia.

DESIGN

We analysed data from the Bettering the Evaluation and Care of Health Program April 2010-March 2016 inclusive. Patient and GP encounter characteristics were extracted. Data were classified by the International Classification of Primary Care, Version 2, and summarised using descriptive statistics and 95% confidence intervals (95% CIs) around point estimates.

RESULTS

The dataset included 583,900 patient-encounter records among which foot/ankle OA was managed 621 times, at a rate of 1.1 per 1000 encounters, with an annual estimated 152,000 GP encounters nationally. The management rate was most frequent among patients aged 65-74 years (2.25 per 1000 encounters). Comorbidities were managed at a rate of 105.8 per 100 encounters, the most common being hypertension, and few being other musculoskeletal problems. Foot/ankle OA was mostly managed using medication (64.6 per 100 problems), with prescription rates far exceeding non-pharmacological strategies such as counselling, advice or education (17.7 per 100), or allied health referral (10.1 per 100). When considering specific health/medical professionals, patients were referred to orthopaedic surgeons 8.4 times per 100 foot/ankle problems, podiatrists 6.3 times per 100 foot/ankle problems, and physiotherapists 2.6 times per 100 foot/ankle problems.

CONCLUSIONS

Pharmacological management rates of foot/ankle OA were high and substantially exceeded non-pharmacological management such as lifestyle advice and allied health referral. Longitudinal studies are needed to determine the effectiveness of this care compared to self-management and conservative non-drug treatment in people with foot/ankle OA.

The Four-card Problem and the Generality of Formal Reasoning

Three experiments were designed to investigate the failure of intelligent adults to solve an apparently simple problem of formal reasoning devised by Wason. Both the mode of presentation and the type of material reduced the difficulty of the problem, while retaining its essential form. However, success on the original problem remained at a low level, even when subjects had attempted an easier version and had been given an explanation.

These results enable one to reject a “strong” formulation of Piaget's theory of formal reasoning. A “weaker” formulation is suggested as a basis for further research.

A descriptive single-centre experience of the management and outcome of maternal alloantibodies in pregnancy

BACKGROUND

Haemolytic disease of the fetus and newborn (HDFN) occurs when maternal IgG alloantibodies to fetal red blood cell antigens cross the placenta, causing haemolysis in the fetus and/or neonate. After delivery, the main concern is hyperbilirubinaemia, which can cause neurological damage.

OBJECTIVES

To summarise our current management and outcome data to inform health-care professionals counselling women whose pregnancies are at risk of HDFN and to compare these data with relevant studies.

METHODS

This is a retrospective descriptive study of all high-risk pregnancies at risk of HDFN at Guy's and St. Thomas' NHS Foundation Trust (GSTFT) Maternity Unit over a 7-year period. We defined high-risk pregnancies as those in whom anti-D, anti-c, anti-K or high (>32 or doubling strength) titres of all other antibodies were identified.

RESULTS

A total of 130 pregnancies in 112 women were followed up. A single alloantibody was found in 93 pregnancies (71.5%) and multiple alloantibodies in 37 pregnancies (28.5%). Anti-D was most commonly encountered (n = 48, 36.9%), followed by anti-c (n = 31, 23.8%) and anti-E (n = 15, 11.5%). In 65 of 130 pregnancies (50%), antibody concentrations triggered scans to screen for fetal anaemia. Of 130 pregnancies, 6 (4.6%) required intrauterine transfusions, and 31 of 130 (26%) neonates required post-natal intervention. Overall, morbidity was 0.1% and mortality 0.002%.

CONCLUSIONS

This study demonstrates that morbidity and mortality caused by HDFN is minimal. These results are reassuring for women at risk of HDFN as even severely affected cases are successfully managed in most instances. Further studies are needed to identify predictors of disease severity.