Telecytology of fine-needle aspiration biopsies of the pancreas: a study of well-differentiated adenocarcinoma and chronic pancreatitis with atypical epithelial repair changes

Four experienced cytopathologists provided consultations using telecytology and routine microscopy. Twenty-seven fine-needle aspiration biopsies (FNABs) from patients with chronic pancreatitis with atypical epithelial repair changes (n = 9) and pancreatic low-grade adenocarcinomas (LG-AC) (n = 18) were studied. False-positive and false-negative diagnostic rates were 19.4% and 12.5% by microscopy and 11.1% and 2.8% by telecytology. Comparisons of agreements between the correct diagnoses and consultations rendered by the two methods and among the diagnoses rendered on the same cases by the two modalities yielded kappa coefficients ranging from 0.444-1.000. Telecytology yielded slightly better kappa coefficients than microscopy. This method, which to our knowledge has not been previously applied to pancreatic FNAB, provides a potentially useful consultative tool for the interpretation of these difficult specimens. The diagnosis of FNAB from patients with chronic pancreatitis and LG-AC is difficult even for experienced consultants, as underscored by the considerable intraobserver and interobserver variability encountered in this study.     

Psychiatric diagnoses of 901 inpatients seen by consultation-liaison psychiatrists at an academic medical center in a managed care environment

The authors reviewed the diagnoses from all inpatient psychiatric consultations conducted by faculty psychiatrists during calendar year 2001 (N = 901) at an academic medical center In about 25% of the consultations, multiple psychiatric diagnoses were made. The most frequent diagnosis groups were mood (40.7%), cognitive (32.0%), and substance use disorders (18.6%). Among 671 consultations in which only one diagnosis was made, the rates of these diagnosis groups were 35.4%, 20.1%, and 10.2%, respectively. The findings were compared with the findings of 19 previous studies published over the past 27 years. Mood, cognitive, and substance use disorders remain major foci of consultation-liaison practice in the managed care era, although the rate of cognitive disorder diagnoses has increased. No evidence was found of a change over time in referral rates.     

Comparing virtual consults to traditional consults using an electronic health record: an observational case¿control study

ABSTRACT: BACKGROUND: Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing "better, faster, cheaper" processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. METHODS: We conducted an observational case-control survey study within Kaiser Permanente, Colorado. A sample of patients who had VC requests (N=270) were matched with patients who had TC requests (N=270) by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. RESULTS: During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (268 out of 540 patients, 49.6% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p=0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. CONCLUSIONS: Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient's perception of care.     

Putting genome-wide sequencing in neonates into perspective

PurposeSeveral studies have reported diagnostic yields up to 57% for rapid exome or genome sequencing (rES/GS) as a single test in neonatal intensive care unit (NICU) patients, but the additional yield of rES/GS compared with other available diagnostic options still remains unquantified in this population.MethodsWe retrospectively evaluated all genetic NICU consultations in a 2-year period.ResultsIn 132 retrospectively evaluated NICU consultations 27 of 32 diagnoses (84.4%) were made using standard genetic workup. Most diagnoses (65.6%) were made within 16 days. Diagnostic ES yield was 5/29 (17.2%). Genetic diagnoses had a direct effect on clinical management in 90.6% (29/32) of patients.ConclusionsOur study shows that exome sequencing has a place in NICU diagnostics, but given the associated costs and the high yield of alternative diagnostic strategies, we recommend to first perform clinical genetic consultation.     

Clinical value of real-time tertiary fetal ultrasound consultation by telemedicine: preliminary evaluation.

Congenital fetal abnormalities are major causes of perinatal mortality and morbidity. The performance of ultrasound in the diagnosis and assessment of fetal anomalies varies enormously between tertiary referral centers and general units. Telemedicine offers a chance for tertiary realtime ultrasound consultations using standard telephone lines for remote sites. Preliminary investigations by our group have shown that real-time transmission of fetal ultrasound images over long distances via telephone (integrated systems digital network [ISDN]) lines is technically feasible. A live link of up to 2 Mb/s was established between Mater Mothers Hospital in Brisbane and Kirwan Hospital for Women in Townsville, which are 1,500 km apart. The objective of the current study was to evaluate the clinical value of a tertiary teleultrasound consultation service. Patients requiring tertiary ultrasound consultations were recruited from North Queensland. Clinicians from the referral site established an initial diagnosis and management plan. Using standard ISDN lines, the real-time ultrasound images were transmitted to the maternal fetal medicine subspecialists in Brisbane. The ultrasound examination was completed under the direction of the subspecialist. The subspecialist explained the findings to the patient at the end of the session, and discussed the diagnosis and management plans with the clinicians involved. Any diagnosis and management variations were classified into minor and major upon agreement by the two teams of clinicians involved. The clinicians and patients in Townsville rated the value of the consultation, and the subspecialists rated the confidence of their diagnoses on five-point scales. Pregnancy outcomes were obtained and the data analyzed. Over a 3-month period, 24 teleultrasound consultations were carried out. The indications for referral were: assessment of growth restriction/fetal wellbeing in the third trimester (6); detailed assessment for high-risk patients (5); evaluation of markers for anomalies (5); isolated fetal anomalies (1); and complex fetal problems such as twin/twin transfusion, multiple anomalies, etc. (7). Overall, the consultations resulted in some modifications to the clinical diagnosis in 45.8% of the cases, and modifications to the management plan in 33.3% of the cases (about half of which were minor variations). The clinicians rated the teleconsultations highly (mean rating 4.7, SD 0.44). The patients also rated the consultations highly, and were comfortable that their privacy and confidentiality were maintained during the consultation. The subspecialists were confident in making their diagnoses by telemedicine (mean score for confidence 4.2, SD 0.43). All the pregnancies have now been completed, with all antenatal diagnoses confirmed to be correct postnatally. Tertiary real-time ultrasound consultation by telemedicine is not only technically feasible, it is welcomed by the clinicians and patients involved. It also contributes to diagnostic and management differences. Larger scale clinical trials are needed to evaluate the true benefits and costs involved. The social benefits in bridging the healthcare gap between the country and the city, and in enabling patients in remote areas to stay close to their family under times of stress is well recognized by all involved.     

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.     

Negotiating exceptions to clients' problem discourse in consultative dialogue

Objective. The purpose of this qualitative study was to examine how consultants negotiated exceptions to clients problem or aspiration discourse in lifestyle consultations held for research purposes. Design. Participants from a university campus (students and employees) were recruited for 1‐hr lifestyle consultations with therapist consultants having graduate training and supervision in narrative and solution‐focused therapy. The consultations were held with the expectation that consultants would, at least once, invite discussions of exceptions in client's problem or aspiration discourse. We wanted to understand how such discussions were initiated and brought to conclusion by examining client and consultants use of conversational practices. Method. Twelve volunteer ‘clients’ participated in consultations with our six volunteering consultants. These consultations were videotaped then passages were selected where consultants initiated exception discussions with the clients involved. The 18 selected passages were discursively analyzed for general rhetorical features evident in those passages, and three passages were transcribed and analyzed using conversation analysis to make evident more specific rhetorical features of exception discussions, as they were engaged in by consultants and clients. Results. Ten general features of exception discussions were highlighted and the more specific conversational analyses revealed a ‘messiness’ that was related to how exception discussions were introduced and negotiated as a novel discourse in the consultations. Conclusions. We discuss our findings in the context of therapists’ use of exception questions and discussions in therapy and highlight particular conversational practices and sensitivities relevant to engaging clients in such exception discussions.     

The course of pregnancy and delivery and the use of maternal healthcare services after standard IVF in Northern Finland 1990-1995

BACKGROUND: The objective of this study was to evaluate the course of pregnancy and delivery and the use of maternal healthcare after IVF. METHODS: This population-based cohort study included all women who had undergone IVF treatment in Northern Finland leading to delivery in 1990-1995 (n = 225) and control pregnancies derived from the Finnish Medical Birth Register (n = 671) matched for sex of the child, year of birth, area, maternal age, parity, social class and fetal plurality. The analyses were stratified by plurality. Outcome measures were pregnancy complications, mode of delivery, gestational length and the level of use of antenatal care. RESULTS: The results showed an increased risk for vaginal bleeding throughout pregnancy [relative risk (RR) 4.1, 95% confidence interval (CI) 2.5-6.7 for singletons; RR 6.9, 95% CI 2.5-19.2 for twins], threatened preterm birth (RR 1.8, 95% CI 1.1-2.9, singletons) and intrahepatic cholestasis of pregnancy (RR 3.8, 95% CI 1.0-15.0, singletons) in IVF pregnancies, as well as an increase in the use of specialized antenatal care. CONCLUSIONS: IVF pregnancies following standard, fresh ova IVF treatments are at greater risk of obstetric problems than spontaneously conceived pregnancies, and hence IVF mothers use more specialized antenatal care than others. The pregnancy complications after IVF are likely to be due to maternal characteristics regarding infertility and to a high incidence of multiple pregnancies.     

Telephone and face-to-face consultation in breast cancer diagnosis: a comparative study

OBJECTIVE: This study compares telephone consultations with the results of clinical examinations to assess the value and accuracy of telephone consultations for the future planning in a breast cancer clinic in Tehran, Iran. METHODS: In 2500 telephone calls, 800 Symptomatic patients were identified and asked to visit the center for the further investigations by the specialists. The agreement between two observers data were compared by the kappa statistic. RESULTS: Totally 174 patients complied with the recommendation and included in the study. The most common chief complaints of visitors were: breast mass (42%) and breast pain (35%). Kappa statistic showed a very good agreement (K=0.62, P<0.001) between consultants' diagnosis and the specialists findings. This agreement for breast cancer diagnosis, although lower, was also good (K=0.55, P<0.001). CONCLUSION: The study findings indicate that consultants may diagnose and manage some common conditions via telephone, usually following the established protocols. More studies are needed to determine the economic and logistic advantages of telephone consultations. PRACTICE IMPLICATIONS: By assessment of strength and weakness of this service, it is possible to develop an easy to use information system for women who need breast care.     

Clarity of request for consultation: its relationship to psychiatric diagnosis

Psychiatric consultants’ ratings of the clarity of requests for 203 psychiatric consultations by medical and surgical services were studied prospectively during a three-month period. The subsequent psychiatric diagnoses were grouped depending on whether or not a major mental illness (MMI), mainly in the form of dementia, delirium, affective disorders, and schizophrenic disorders, was present according to DSM-III criteria. An MMI was diagnosed in 61% of cases in which the reason for the consultation request was considered unclear, but in only 32% of cases in which the reason was considered clear. These findings support earlier speculations that patients with serious psychiatric disturbances tend to affect the clarity of communications among members of the treatment team.     

Antenatal care in singleton pregnancies after ICSI as compared to spontaneous conception: data from a prospective controlled cohort study in Germany

BACKGROUND: The aim was to compare the antenatal care and the intake of vitamins and medications of infertility patients with singleton pregnancies after ICSI to women with a spontaneously conceived singleton pregnancy. METHODS: The data on the antenatal care of 2055 singleton pregnancies after ICSI from a prospective controlled multicentre study in Germany were analysed. The prospectively collected data of the control group of 7861 singletons were retrospectively assessed for the present analysis. RESULTS: The ICSI patients were significantly older (32.9 versus 27.0 years, P<0.019) and more likely to be obese (body mass index>or=30 kg/m2: 13.9 versus 4.8%, P<0.001) than the controls. The control mothers were significantly more likely to smoke (19.2%) or to consume alcohol (23.5%) during pregnancy than the ICSI mothers (7.4 and 0.6% respectively). Only 38.1% of ICSI patients took folic acid before conception. Only 61.7% of ICSI patients received an iodine supplementation at some point during pregnancy. ICSI patients went more regularly to the routine antenatal care consultations at the gynaecologist and had ultrasound examinations performed more regularly than the controls. The absolute number of ultrasound examinations was significantly higher in the ICSI group (13.6+/-6.0 versus 4.1+/-2.4). CONCLUSION: In spite of the intensive use of antenatal medical care by patients pregnant after ICSI, simple methods, such as the use of supplementary iodine and periconceptional folic acid, were used rarely. This indicates that counselling pregnant patients after ICSI about periconceptional and antenatal care seems to be insufficient in Germany and must be improved.     

The safety and efficacy of chorionic villus sampling for early prenatal diagnosis of cytogenetic abnormalities

Chorionic villus sampling is a method of prenatal diagnosis in the first trimester of pregnancy in which tissue for genetic study is aspirated from the developing placenta by means of a catheter inserted transcervically under the guidance of ultrasonography. In this seven-center study, we compared the safety and efficacy of chorionic villus sampling in 2278 women with those of amniocentesis at 16 weeks' gestation in 671 women. Both groups were made up primarily of well-educated private patients; they were recruited in the first trimester of pregnancy and had viable pregnancies verified by ultrasound examination. Cytogenetic diagnoses resulted from 97.8 percent of the chorionic villus sampling procedures and 99.4 percent of the amniocenteses (P less than 0.05); aneuploidy was found in 1.8 and 1.4 percent, respectively, of the cases in which diagnoses were made. Of the women who underwent chorionic villus sampling, 17 (0.8 percent) subsequently had an amniocentesis because the diagnosis was ambiguous. Two of the diagnoses of aneuploidy (one tetraploidy, one trisomy 22) were later proved to be incorrect. On the basis of pediatric examination of the infants subsequently born to the women in the sample, there were no errors in the determination of sex or the identification of the major trisomies (21, 18, and 13). The rate of combined losses due to spontaneous and missed abortions, termination of abnormal pregnancies, stillbirths, and neonatal deaths was 7.2 percent in the group that underwent chorionic villus sampling and 5.7 percent in the group that had amniocentesis. After adjustment for slight differences in gestational and maternal age, the total loss rate for the women in the chorionic villus sampling group exceeded that for the amniocentesis group by only 0.8 percentage points (80 percent confidence interval, -0.6 to 2.2). The rate of loss of chromosomally normal fetuses after chorionic villus sampling was 10.8 percent among women in whom three or four attempts were made to place the transcervical catheter, as compared with 2.9 percent in those in whom only one attempt was necessary (P less than 0.01). There were no serious maternal infections among the women in this study or among an additional 1990 women who underwent chorionic villus sampling (upper 95 percent confidence limit, 0.08 percent). We conclude that chorionic villus sampling is a safe and effective technique for the early prenatal diagnosis of cytogenetic abnormalities, but that it probably entails a slightly higher risk of procedure failure and of fetal loss than does amniocentesis.     

The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.

BACKGROUND: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. AIM: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. DESIGN OF STUDY: Retrospective cohort study. SETTING: Eighteen general practices in the Exeter Primary Care Trust. METHOD: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations. RESULTS: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. CONCLUSION: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.     

The placenta in pre-eclampsia and intrauterine growth restriction

Placental examination in pregnancies with complications such as pre-eclampsia/toxaemia of pregnancy (PET) or intrauterine growth restriction (IUGR) can provide insight into specific diagnoses, recurrence risk and chronicity. Placental findings have clinical significance as they can identify the aetiology of the IUGR (as in inborn errors of metabolism) and predict recurrence (as in maternal floor infarcts). Evaluation of obstetric pathology in such pregnancies should be an integral part of clinical care. This review will highlight the placental findings in IUGR and PET.     

Provider–patient interaction in rural Cameroon—How it relates to the patient's understanding of diagnosis and prescribed drugs,the patient's concept of illness,and access to therapy

Objective

This cross-sectional survey examines the relation between provider–patient interaction and several patient-outcomes in a rural health district in Cameroon.

Methods

We used structured patient interviews and the Roter Interaction Analysis System (RIAS) for analysis of audio-recorded consultations.

Results

Data from 130 primary care consultations with 13 health-care providers were analysed. 51% of patients correctly named their diagnoses after the consultation; in 47% of prescribed drugs patients explained correctly the purpose. Patients’ ability to recall diagnoses was related to the extent of clarity a provider used in mentioning it during consultation (recall rates: 87.5% if mentioned explicitly, 56.7% if mentioned indirectly and 19.2% if not mentioned at all; p < 0.001). Two thirds of patients were able to describe their concept of illness before the consultation, but only 47% of them mentioned it during consultations. On average patients who mentioned their disease concept were faced with more remarks of disapproval from providers (1.73 vs 0.63 per consultation; p < 0.01). Although 41% of patients admitted problems with financial resources to buy prescribed drugs, discussion about financial issues was very rare during consultations. Providers issued financial questions in 32%, patients in 21% of consultations.

Conclusion

This study shows that provider–patient interaction in primary health care in a rural Cameroon district deserves more attention. It might improve the patients’ knowledge about their health condition and support them in beneficial health behaviour.

Practice implications

Our findings should encourage providers to give more medical explanation, to discuss patients’ health beliefs in a non-judgemental manner, and to consider financial issues more carefully.     

Lifetime prevalence of infertility and infertility treatment in the UK: results from a population-based survey of reproduction

BACKGROUND: The aim of this study was to investigate the prevalence of infertility and the use of infertility treatment among women aged 40-55 years. METHODS: Population-based postal questionnaire survey of UK women. Over 60,000 women randomly sampled from the 2001 electoral roll were sent a questionnaire, and those aged 55 years and under who had ever been pregnant or tried to achieve a pregnancy (n = 6584) were asked to provide a reproductive history. RESULTS: Overall, 2.4% of women aged 40-55 years had unresolved infertility with no pregnancies, and a further 1.9% had been pregnant but not achieved a live birth. The prevalence of unresolved fertility did not differ among birth cohorts. Sixteen percent of women reported ever consulting a doctor because of infertility and 8% reported receiving treatment to conceive. Across the whole sample, 4.2% of women reported that they had achieved at least one pregnancy as a result of treatment. Compared with earlier birth cohorts, women born later were more likely to report consultations (18% versus 13%) and treatment (9% versus 6%) for infertility, and pregnancies as a result of infertility treatment (6.7% versus 2.7%). Among those who reported medical consultations, women born more recently first consulted at a later age compared with those born earlier. CONCLUSIONS: Although both the number of women seeking medical care for infertility and the proportion reporting pregnancies as a result of infertility treatment has increased, there is no evidence to support an overall increase in unresolved infertility over the past 15 years. The vast majority of women aged 40-55 who reported difficulties conceiving did have a child, or children, at some point in their lives.     

Paediatric palliative care: development and pilot study of a ‘Directory’ of life-limiting conditions

Background

Children’s palliative care services are developing. Rational service development requires sound epidemiological data that are difficult to obtain owing to ambiguity in the definitions both of the population who needs palliative care and of palliative care itself. Existing definitions are of trajectory archetypes. The aim of this study was to develop and pilot a directory of the commonest specific diagnoses that map on to those archetypes.

Methods

The diagnoses of patients under the care of five children hospices and a tertiary specialist palliative medicine service in the UK were recorded. Duplicates and diagnoses that were not life-limiting conditions according to the ACT/RCPCH criteria or were not primary were removed. The resulting Directory of life-limiting conditions was piloted by analysing Death Certificate data of children in Wales between 2002 and 2007.

Results

1590 diagnoses from children’s hospices and 105 from specialist palliative medicine were combined. After removals there were 376 diagnostic label. All ICD10 chapter headings were represented by at least one condition. The pilot study showed that 569 (54%) deaths in Wales were caused by LLC. Only four LLC resulted in ten or more deaths. Among deaths from LLC, the ten commonest diagnoses accounted for 32%, while the 136 diagnoses that caused one or two deaths accounted for 25%. The majority occurred from a small number of life-limiting conditions.

Conclusion

The Directory is a practical tool for identifying most life-limiting conditions using ICD10 codes that facilitates extraction and analysis of data from existing sources in respect of life-limiting conditions in children such as death certificate data, offering the potential for rapid and precise studies in paediatric palliative care.