Variation in Spending Associated With Primary Care Practices

Am J Manag Care. 2021;27(7):297-300. https://doi.org/10.37765/ajmc.2021.88557 _____ Takeaway Points Physician practices account for a significant amount of variation in spending. * There is widespread variation in spending associated with physician practices. * This likely reflects variation in utilization and in the prices of care delivered by the practice and the sites they refer to. * Significant savings can be obtained if patients shift from practices associated with high spending to those with low spending. _____ Although the country is making preliminary steps toward recovery, the COVID-19 pandemic has sent the United States into its most significant economic downturn since the Great Depression, which will significantly exacerbate pressure for employers to control health care spending. A large body of literature documents the significant variation in prices within markets, from which it can be inferred that considerable cost-saving opportunities are associated with price shopping.1 Importantly, physician practice prices have not been found to be associated with quality or efficiency metrics.2 The literature on practice style variation suggests that there may also be savings opportunities from identifying physicians with less intensive practice styles.3 For example, physician beliefs about treatment regimens contribute to significant regional differences in physician practice spending.4 Similarly, physician experience is associated with spending, as less experienced primary care physicians (PCPs) and specialists have higher overall costs.5 Much of the practice variation literature focuses on market-level analysis, which masks widespread variation within geography.6,7 For this reason, the National Academy of Medicine has called for greater understanding of variation attributable to physician practice styles.8 We extend the nascent research on this topic using unique data on commercial prices and spending. [...]patient preferences regarding specialist visits are associated with higher specialist utilization, suggesting that other factors besides PCP referrals can play significant roles in care usage.9 Moreover, research has shown that patients are often unwilling to sacrifice time or money to maintain continuity of care with PCPs;such continuity is associated with better outcomes and more cost-effective care.10 However, given that PCPs serve as a first contact and main provider for most individuals, identifying variation in practice spending and prices still provides valuable insight into how best to utilize primary care efficiently. Because we controlled for 3-digit zip code, the quartiles should be interpreted as relative to other practices in their 3-digit zip code.

The Disease Management Experiences of Patients with Stroke during the Covid-19 Pandemic: A Qualitative Study

Background: The pandemic, COVID-19, has disrupted the delivery of healthcare services. The admissions of patients with stroke to hospitals decreased during the pandemic. There is considerable uncertainty about how patients with stroke manage their illnesses beyond the control of healthcare professionals during the pandemic period. Aim: Our study aimed to determine the experiences of patients with stroke regarding disease management during the pandemic period. Methods: This study had a descriptive qualitative design. The study was conducted with 18 patients with stroke registered in the Stroke Outpatient Clinic of Hospital X. A patient information form and a semi-structured interview form were used, and video-online in-depth interviews were conducted with each patient and recorded. After the interviews, the records were directly transcribed and analyzed. The transcripts were analyzed using thematic content analysis. Results: As a result of our study, five main themes were reached. These themes are;difficulty in access to healthcare, fear, change in the flow of daily life, inability to access sufficient information, and adaptation. Conclusion: As a result of our study, it is seen that patients with stroke have difficulties due to pandemic conditions, and individual and institutional solutions have been developed for these difficulties over time. It is recommended to create accessible health systems, increase online health services, and implement initiatives that support patients with stroke in bio-psycho-social aspects, for all extraordinary conditions that may be experienced.

Understanding the benefits and limitations of a blended approach (mixing virtual and face-to-face consultations) to medical outpatient palliative care services: a mixed-methods study

BackgroundThe Covid-19 pandemic led to a rapid increase in the use of virtual technologies (telephone;video) across healthcare. For palliative care patients, further evidence is required to inform integration of virtual technologies with traditional face-to-face consultations.AimTo understand the benefits and limitations of a blended approach (mixing virtual and face-to-face consultations) to medical outpatient palliative care consultations.MethodsA mixed-methods study with a concurrent triangulation design was conducted. Phase 1 comprised an anonymous online survey of palliative medicine physicians in the UK. Survey questions were derived following a review of the literature and explored physicians' experiences and opinions of different consultation modalities. Phase 2 comprised qualitative semi-structured interviews with palliative medicine patients exploring their perspectives of virtual and face-to-face outpatient clinics. Patients were recruited from palliative medicine outpatient clinics and interviewed via Microsoft Teams. Results from both phases were integrated and recommendations for clinical practice developed.ResultsThe online survey received 48 responses from professionals, and eight semi-structured patient interviews were conducted. Patients and physicians felt face-to-face consultations were necessary for clinical assessments and improved communication and relationship building. The main challenge was the physical burden from travel. Telephone consultations were useful for simple and finite problems such as medication reviews, but the physical separation introduced communication barriers and prevented clinical assessment. Video technologies supported physically-limited patients to access clinics and allowed for some clinical assessment to occur. The most appropriate modality for breaking bad news and/or providing psychosocial support was felt to be patient and situation dependent.ConclusionThe use of a blended approach to palliative medicine outpatient clinics is acceptable to patients and physicians and has the potential to capitalise on the benefits of each modality to deliver an effective and efficient service.

How Health Systems Can Survive: The Case of Musculoskeletal Care

Healthcare represents 19.7% of the gross national product, making it one of the largest expenses for all U.S. companies. It crowds out investment for growth and is generally considered unsustainable. And the biggest cost is hospitals. Every manager has a vested interest in lowering the cost of care and increasing the viability of hospitals in their community. More than 10% of U.S. hospitals are at immediate risk of closing because of financial losses and lack of financial reserves. Over 70% of 900 hospitals surveyed reported a decrease in operating revenue over the last year. The COVID-19 pandemic provided momentum toward developing alternative deliveries of care, including virtual health, home, and outpatient care. This has created a rapid, massive shift away from hospital-based care. Perhaps the greatest risk is the largest opportunity-to find solutions to this financial crisis in the rapidly changing revenue dynamic of subspecialties, with musculoskeletal care being the prime example. Alternative sites of care and innovative care delivery are being financed by capital market investment. One solution to this crisis is for hospitals to collaborate with capital market-backed companies creating a novel business model.

Identifying built environment solutions, in Thai community hospital outpatient clinics, to prevent the spread of COVID-19

Due to the unprecedented outbreak of COVID-19 (Corona Virus Disease - 2019) healthcare facilities, including Thailand community hospitals were mandated to adjust their facilities to both medical and non-clinical areas to prevent the spread of the disease. The study aimed to identify problems focusing on the physical settings of out-patient departments (OPD) in community hospitals during the first Thailand COVID-19 outbreak in March 2020. Furthermore, the study focused on providing design suggestions for preventing the spread of respiratory infectious diseases. The study employed a two-step approach to data collection. First, physical setting observations of the OPD of the two hospital buildings. Second, interviews with 22 healthcare employees;11 participants from the first hospital and 11 participants from the second hospital. Interviews were transcribed verbatim and analyzed using content analysis. Five main themes were identified: (1) factors leading to accumulation of pathogens, (2) measures for preventing the spread of respiratory diseases, (3) current services and physical settings of outpatient clinics, (4) guidelines for improving the physical setting of outpatient clinics and (5) prevention of accumulation of pathogens in OPD areas. Results indicate that not only improving the physical setting of the OPD areas is required, but a strict patient screening process and an organized building management programme should also be considered. Such actions with workflow management would have played important roles in preventing the spread of respiratory diseases during the first COVID-19 outbreak. The findings from the study contribute to both research and industry. For the research, the study contributes to three literature topics including hospital building evaluation and assessment techniques, hospital design, and design prevention for the spread of COVID-19. For industry, the study contributes to the future development of layout design that can prevent the spread of COVID-19 throughout Thai community hospitals.

The Development of a Post COVID-19 Clinic at the University General Hospital of Ioannina in Greece

In recent years, the global world is facing the COVID-19 pandemic, which has caused significant long-term consequences to the population's health. Post COVID-19 is considered an implication of the various that has drawn the attention of the scientific world, as the reported cases are increasing rapidly globally and the danger of permanent disorder is real. This article focuses on the significance of specialized clinics for post COVID-19 cases and on their working methods. Hence, the example of the establishment of a specialized clinic in the University General Hospital of Ioannina (U.G.H.I.) is provided, based on a SWOT analysis, while at the same time a realistic approach to its development is presented. The proper therapeutic approach of the people that suffer from the post COVID-19 will contribute to the protection and well-being of the society, dealing effectively, in this way, with the problems caused by the of the ongoing SARS-CoV2 pandemic.

Evaluation of the Relationship of Fatigue, Anxiety and Depression Levels in Individuals with the Precautions Taken in the COVID-19 Pandemic Process

Objective: This study aims to evaluate the effects of the COVID-19 process and the measures taken on fatigue, anxiety and depression levels in individuals, and the factors that may cause this effect. Methods: The study is of cross-sectional type. A total of 281 participants who applied to the pandemic outpatient clinic were included in the study. Data collection form with 27 questions and Hospital Anxiety and Depression Scale (HADS) with 14 questions were used in the study. Relationships between data were evaluated with t-test and chi-square test in independent groups. The importance levels of the factors affecting the anxiety and depression scores were determined by the Chaid Analysis. Statistically, cases with p<.05 were considered significant. Results: A total of 281 participants, with a mean age of 40.09±12.35 years and 56.2% women, were included in the study. The mean depression score of the participants in HADS was 7.43±3.85. The mean anxiety score was 8.11±4.04. 61.6% of the participants had depression and 31.0% had anxiety. According to Chaid’s analysis, the most effective factor on anxiety and depression scores was that the fear of contracting the COVID-19 infection exhausted the individual. Conclusion: As a result of the research, it was found that the frequency of depression and anxiety was high in patients who applied to the pandemic outpatient clinic. It was determined that more than half of the participants were afraid of catching an infection and this fear caused fatigue in them. Mental health should not be ignored during the pandemic period and both physical and mental health of people should be protected with holistic approaches.

Evaluation of Immune Response in Asymptomatic Children with Parents withCOVID-19

According to the May 2021 data of the World Health Organization (WHO), more than 165 million people were infected in 206 countries, over 3.4 million people were lost and over 1.4 billion people were vaccinated with the start of vaccination studies1. According to recent studies, children make up a small proportion of COVID-19 cases2. METHODS For the study, after receiving the approval of the Local Ethics Committee, dated 07.05.2021 and numbered 754, the children who applied to the Pediatrics Outpatient Clinic for routine controls between May and June 2021, who had no symptoms and were not tested by RT-PCR although their parents and close relatives were positive for COVID-19 by RT-PCR (reverse transcription polymerase chain reaction) in the last 6 months, were evaluated prospectively. The antibody levels were measured with the Abbott Architect Í2000SR (Abbott Diagnostics, USA) using the original kits (Abbott SARS-CoV-2 IgG, which is designed to detect IgG antibodies against the nucleocapsid protein of SARS CoV-2 and SARS- CoV-2 IgG II, which is designed to detect IgG antibodies against the receptor binding region [RBD] of the spike protein S1 subunit of SARS CoV-2) were tested after running two-level quality control.

Royal hospital for children – telephone outpatient clinic patient feedback questionnaire

AimsSince March 2020 most General Paediatric Outpatient appointments have been carried out by telephone due to COVID-19 restrictions. This study explored families’ views and satisfaction with remote consultations for new patient appointments.MethodsFrom March to June 2021, all families whose child received a telephone appointment for a new clinical problem were invited to complete an online structured questionnaire with 17 questions containing rating scales, or yes/no answers. Questions related to ease of communication, preferences about type of Outpatient appointment, and overall satisfaction. There was a free-text box for additional comments. All families were contacted about the questionnaire through an attachment with the appointment letter and a follow-up text message or email. A third point of contact in the form of a phonecall was attempted for families with appointments in May or June. All new appointments were 30 minutes long and conducted by a group of 25 Consultant Paediatricians.ResultsOf 1209 outpatient appointments, 221 families (18.3%) completed the questionnaire.  Regarding communication: 210 (95%) reported there was sufficient time in the appointment and, out of a score of 10, Ease of communication was rated 8.34, Listening skills of the Consultant 9.15 and Clarity of management plan 8.57. 48 patients (21.7%) were discharged after the consultation, and in total 102 patients (46.2%) were not assessed to require a follow-up face-to-face appointment (FTF).Exploring preferences, 103 families (46.6%) thought that a FTF would have been better than a telephone appointment (TP), 92 (41.6%) were happy with a phone appointment, and 26 (11.8%) were unsure. However, 171 families (77.4%) would be happy to have a TP again for a new problem. Around one third considered a video appointment would be preferable to a TP (77 families, 34.8%) and 90 families (40.7%) felt that a video appointment would be as good or worse, 54 families (24.5%) were unsure.Relating to overall satisfaction, carers gave a satisfaction rating of 8.71/10, and the 59 children (26.7%) who were able to take part in the TP 7.78/10. 128 families (57.9%) provided additional comments, most were positive comments about the appointment and preferences for a FTF in future. Negative comments mainly related to difficulty in communication (13), the management plan (8) or administration issues (8).ConclusionDespite a significant shift in the delivery of Outpatient services, families felt they were listened to, had time to talk about their concerns, and were clear about management plans. Overall, they were satisfied with the consultations, although almost half would have preferred a FTF. Many families did not complete the questionnaire, and this non-response bias must be considered in the interpretation of results. However, there were no official complaints about TPs during this period.Going forward, there is a role for TPs, particularly for certain conditions which can be well described, and if the child has been examined recently in Primary Care. TPs reduce transport costs and travel time for families, and have a major impact on the carbon footprint of Outpatient services.

CMS Rules and Actions to Monitor in November: 2022 Final Physician Fee Schedule and Site-Neutral Payments for Off-Campus Clinics

Certain specialty procedures are slated to decrease significantly, like thrombectomies (-22%) and angiograms with Stents (-22%).3 Given the rule's potential for a significant financial impact on physician practices, leaders will need to watch closely as CMS releases the 2022 final rule in November. [...]the rule also proposed changes to the weighting of MIPS performance categories, with Quality shifting from 40% weight to 30% and Cost shifting from 20% to 30%1. "Medicare has closed the gap between the inpatient and the hospital outpatient reimbursement rates, effectively eliminating any monetary incentive to perform a total knee replacement as an inpatient case," said Matt Reigle, associate principal of ECG Management Consultants, during a Becker's Healthcare ASC conference.5 Additional efforts to shift outpatient services into lower-cost care settings may be included in forthcoming CMS rules in the near future.

Evaluation of the impact of COVID-19 pandemia on pediatric urological operations and the number of outpatient clinic patients in a province with, the highest birth rate Turkey

Investigation of the effect of Covid-19 pandemic on pediatric urology operations in Şanliurfa province, where the birth rate is the highest in Turkey : Objective: The aim of this study is to investigate the effect of the COVID-19 pandemic on pediatric urology operations. Materials and Methods: Hospital records of pediatric patients who applied to Harran University Medical Faculty Pediatric Urology Clinic during the pandemic period (19 March-22 December 2020) and pre-pandemic period (19 March-22 December 2019) and were operated with precautions were retrospectively analyzed. The number of outpatient clinic patients during and before the pandemic period, the number of operations and indications, and the types of surgery were compared. The names and numbers of surgical procedures are listed according to the European Association of Urology (EAU) priority classification. Results: During the COVID-19 pandemic period, the number of pediatric patients admitted to the outpatient clinic was 2361, while it was 5214 in the same period before the pandemic. It was observed that the number of patients who applied to the outpatient clinic decreased by 54.8% during the pandemic period. While the total number of pediatric operations was 316 during the pandemic period, it was 741 before the pandemic period. When the pandemic period was compared with the pre-pandemic period, a 58.4% reduction was observed in pediatric urology operations. The number of emergency operations was 69 during the pandemic period and 85 in the pre-pandemic period. During the pandemic period, the reduction in emergency operations was 18.8%. No complications were observed due to COVID-19 in any of the operated patients. Conclusion: During the COVID-19 epidemic, it was observed that the number of pediatric urology outpatient clinic admissions and surgeries in our hospital decreased. In cases where urgent interventions were required, adequate precautions were taken, and surgical operations could be applied without any contamination and mortality. Keywords: Coronavirus, coronavirus disease 2019, pandemic hospital, pediatric urological surgery.Alternate :et Amaç: Bu çalışmada COVID-19 pandemisinin pediatrik üroloji ameliyatlarına etkisini araştırmayı amaçladık. Materyal ve metod: Tıp Fakültesi Pediatrik Üroloji Kliniği’ne pandemi döneminde (19 Mart-22 Aralık 2020) ve pandemi öncesi dönemde (19 Mart-22 Aralık 2019) polikliniğe başvuran ve önlemler eşliğinde ameliyat edilen pediatrik hastaların hastane kayıtları retrospektif incelendi. Pandemi dönemi ve öncesi poliklinik hasta sayıları, ameliyat sayıları ve endikasyonları, ameliyat türleri karşılaştırıldı. Cerrahi prosedürlerin isimleri ve sayılar Avrupa Üroloji Derneği (EAU) öncelik sınıflandırmasına göre listelendi. Bulgular: COVID-19 pandemisi döneminde polikliniğe pediatrik hasta başvuru sayısı 2361 iken pandemi öncesi aynı dönemde 5214 idi. Pandemi döneminde polikliniğe başvuran hasta sayısının % 54,8 azaldığı görüldü. Pandemi döneminde toplam pediatrik ameliyat sayısı 316, pandemi dönemi öncesi 741 idi. Pandemi dönemi, pandemi öncesi ile karşılaştırıldığında pediatrik üroloji ameliyatlarında %58,4 azalma olduğu görüldü. Pandemi döneminde acil ameliyat sayısı 69, pandemi öncesi dönemde 85 idi. Pandemi döneminde acil ameliyatlardaki azalma %18,8 idi. Opere edilen hiçbir hastada COVID-19 nedeniyle komplikasyon izlenmedi. Sonuç: COVID-19 salgını sırasında hastanemizdeki pediatrik üroloji poliklinik başvurusu ve ameliyat sayısının azalmış olduğu görüldü. Acil müdahalelerin gerekli olduğu olgularda yeterli önlemler alınarak, herhangi bir kontaminasyon ve mortalite olmaksızın cerrahi operasyonlarının uygulanabilirliği görüldü.

Mixed-methods study to examine the response of opioid addiction treatment programmes to COVID-19: a study protocol

IntroductionThe COVID-19 pandemic is forcing changes to clinical practice within traditional addiction treatment programmes, including the increased use of telehealth, reduced restrictions on methadone administration (eg, increased availability of take-home doses and decreased requirements for in-person visits), reduced reliance on group counselling and less urine drug screening. This paper describes the protocol for a mixed-methods study analysing organisational-level factors that are associated with changes in clinic-level practice changes and treatment retention.Methods and analysisWe will employ an explanatory sequential mixed-methods design to study the treatment practices for opioid use disorder (OUD) patients in New York State (NYS). For the quantitative aim, we will use the Client Data System and Medicaid claims data to examine the variation in clinical practices (ie, changes in telehealth, pharmacotherapy, group vs individual counselling and urine drug screening) and retention in treatment for OUD patients across 580 outpatient clinics in NYS during the pandemic. Clinics will be categorised into quartiles based on composite rankings by calculating cross-clinic Z scores for the clinical practice change and treatment retention variables. We will apply the random-effects modelling to estimate change by clinic by introducing a fixed-effect variable for each clinic, adjusting for key individual and geographic characteristics and estimate the changes in the clinical practice changes and treatment retention. We will then employ qualitative methods and interview 200 key informants (ie, programme director, clinical supervisor, counsellor and medical director) to develop an understanding of the quantitative findings by examining organisational characteristics of programmes (n=25) representative of those that rank in the top quartile of clinical practice measures as well as programmes that performed worst on these measures (n=25).Ethics and disseminationThe study has been approved by the Institutional Review Board of NYU Langone Health (#i21-00573). Study findings will be disseminated through national and international conferences, reports and peer-reviewed publications.

The Effect of the First Coronavirus Lockdown on Psychiatric Outpatient Attendance, a North Fife Survey

AimsThere has been a significant change in the way we see patients during psychiatric consultations, this has led to challenges we face in delivering safe and effective care to patients under our care. “Telepsychiatry” has been used in literature from countries like Australia and India, there is very little around coming from the UK but there appears to be many ongoing research making the rounds. It is interesting to know that the existing literature on remote/virtual consultations during the COVID-19 pandemic are on the rise. The idea of this study was conceived during outpatient clinics after making an observation that many patients were likely to miss their appointments when they had telephone appointments compared to video consultations. This prompted a study to know if this is more likely to be observed in other outpatient clinics. The purpose of this study was to establish if virtual/remote consulting has affected patient attendance rate and whether this is also affected by the type of virtual consultation.MethodsThe data were collected using the “2020 stats sheets” for inpatient appointments between North Fife consultants from January to October 2020. This was registered with the NHS Fife clinical effectiveness team in January 2021.ResultsThe results were categorized for the purpose of this survey as January – March (Pre-lockdown) and April – October (lockdown). It is important to note that some face-to-face appointments occurred during lockdown because there were emergency assessments and drug monitoring appointments scheduled.The results of this survey showed that there was a clear reduction in clinic appointments made during lockdown compared to pre-lockdown and slight observable improvement in attendance rates during the lockdown. There was no statistical significance seen using t-test comparing attendance rates between video and telephone consultations including new patient virtual consultations.ConclusionThe large sample size over this period suggests that the results are reliable and valid, we can therefore say virtual/telephone consultation does not affect attendance. It should be noted that the attendance rate may be a good indicator but we should also consider patient/clinician satisfaction, communication quality/effectiveness and other factors which could influence patient's compliance to outpatient follow-up. It is important to acknowledge the lack of a control group and the COVID-19 pandemic were major cofounding factors. Mental health services should continue the use of virtual consultation post-pandemic and possibly integrate it with in person consultations (hybrid), this may help with attendance rate of patients with difficulty attending face-to-face appointments.

A Tricky Balance: Medicare's Affordability and Middle- and Lower-Income Beneficiaries' Financial Stress

Under Medicare, older Americans have access to government-subsidized health insurance to protect them from catastrophic healthcare costs and ensure access to needed care. And yet, one in ten Medicare beneficiaries report delaying care due to cost, and 6 percent report having problems paying medical bills. The health and economic impacts of the coronavirus pandemic have exacerbated issues of healthcare affordability for older adults, particularly those with low incomes. This article reviews the financial impact of gaps in the Medicare program, and proposals designed to meet Medicare beneficiaries' evolving needs.

Effectiveness of video consultations in type 1 diabetes patients treated with insulin pumps in the outpatient clinic: protocol for a randomised controlled trial

IntroductionThe purpose of the study is to assess the effectiveness of video consultations in patients with type 1 diabetes mellitus (DM) treated with insulin pumps in the outpatient clinic.Methods and analysisA 52 weeks’ duration, open-label, randomised controlled trial will be conducted, enrolling 100 patients with type 1 DM currently treated with insulin pump.Patients will be recruited from the diabetes outpatient clinic at Hospital of Southern Jutland, Department of internal medicine, Sønderborg. Participants will be randomised to either video consultations (experimental intervention) or standard care (control comparator). Participants in the video consultation group will follow their standard care treatment but will have all of their scheduled and non-scheduled appointments by video consultation. The control group will follow their standard care treatment as usual, having all their appointments at the outpatient centre. Primary outcome will be change from baseline of time in range (3.9–10.0 mmol/L).Ethics and disseminationThe study has been approved by the Regional Committe on Health Research Ethics for Southern Denmark, S-20200039G Acadre 20/12922. We will present the results of the trial at international conferences as well as publish the results of the trial in (a) peer-reviewed scientific journal(s).Trial registration numberNCT04612933.

Objective Home-Monitoring of Physical Activity, Cardiovascular Parameters, and Sleep in Pediatric Obesity

Introduction: Clinical research and treatment of childhood obesity is challenging, and objective biomarkers obtained in a home-setting are needed. The aim of this study was to determine the potential of novel digital endpoints gathered by a home-monitoring platform in pediatric obesity. Methods: In this prospective observational study, 28 children with obesity aged 6–16 years were included and monitored for 28 days. Patients wore a smartwatch, which measured physical activity (PA), heart rate (HR), and sleep. Furthermore, daily blood pressure (BP) measurements were performed. Data from 128 healthy children were utilized for comparison. Differences between patients and controls were assessed via linear mixed effect models. Results: Data from 28 patients (average age 11.6 years, 46% male, average body mass index 30.9) and 128 controls (average age 11.1 years, 46% male, average body mass index 18.0) were analyzed. Patients were recruited between November 2018 and February 2020. For patients, the median compliance for the measurements ranged from 55% to 100% and the highest median compliance was observed for the smartwatch-related measurements (81–100%). Patients had a lower daily PA level (4,597 steps vs. 6,081 steps, 95% confidence interval [CI] 862–2,108) and peak PA level (1,115 steps vs. 1,392 steps, 95% CI 136–417), a higher nighttime HR (81 bpm vs. 71 bpm, 95% CI 6.3–12.3) and daytime HR (98 bpm vs. 88 bpm, 95% CI 7.6–12.6), a higher systolic BP (115 mm Hg vs. 104 mm Hg, 95% CI 8.1–14.5) and diastolic BP (76 mm Hg vs. 65 mm Hg, 95% CI 8.7–12.7), and a shorter sleep duration (difference 0.5 h, 95% CI 0.2–0.7) compared to controls. Conclusion: Remote monitoring via wearables in pediatric obesity has the potential to objectively measure the disease burden in the home-setting. The novel endpoints demonstrate significant differences in PA level, HR, BP, and sleep duration between patients and controls. Future studies are needed to determine the capacity of the novel digital endpoints to detect effect of interventions.

How Substance Use Treatment Services in Iran Survived Despite a Dual Catastrophic Situation

The prevalence of opium, residual opium juice (shireh), crystal methamphetamine, hashish, and heroin use in Iran is 150, 660, 590, 470, and 350 per 100 000 population, respectively.1 Substance use disorder is ranked as one ofthe top four health burdens in Iran.2 Addressing this health crisis has required the legalization of a variety of treatments and harm reduction services, the domestic production of opioid medications, available and low-cost opioid medications, available opium tincture with its short induction period, using seized opium to produce opium tincture, online self-help groups, and coordination among government agencies, the private health care sector, and nongovernmental organizations. HARM REDUCTION SERVICES IN IRAN The largest number of patients are served in private outpatient clinics that offer opioid agonist treatment, although abstinence-based residential centers and therapeutic communities are available in the private sector and the government runs compulsory residential centers.6 In 2018, an estimated 60 000 persons were under methadone maintenance treatment (MMT) while in prison, about 720 000 community residents were receiving MMT, approximately 120 000 were receiving buprenorphine, and about 93 000 were receiving opium tinctures from 1 of 196 government-run outpatient clinics or one of 7029 private outpatient clinics.6 Harm reduction services and facilities such as drop-in centers and outreach programs provide needle and syringe programs, low-threshold methadone treatment, condom promotion, and safer sex education. [...]clinics were authorized to provide larger take-home supplies of methadone, buprenorphine, and opium tincture for their stable patients.8 Although patients did not experience any shortage of opioid maintenance medications, there were fewer psychological services available because of COVID-19 prevention policies and the lack of online services. Methadone is also much less expensive than buprenorphine, and there are seven times more methadone patients than buprenorphine patients in Iran.10 Moreover, local opium tincture manufacture uses seized opium,11 which reduces production costs.12 * Reducing the need for harm reduction: Because of the availability of opioid maintenance medications, in past years the number of PWID decreased and the impact of this is seen in the reduced prevalence of HIV among PWID in Iran.13 This phenomenon has reduced the costs of harm reduction services because fewer harm reduction facilities are needed.

Changes in medical oncology practice due to the COVID-19 pandemic in Turkey, and the risk of neglect of cancer patients

The reduced access to healthcare resources, the limited access to healthcare services and the difficulties faced in planning treatment strategies for cancer patients are thought have resulted in negative outcomes not just in the short term, but also in the medium and the long terms. The Ministry of Health of the Republic of Turkey has published general instructions informing all physicians to cease surgeries other than urgent interventions and those for cancer, aiming to minimize the risk of infection, to shorten hospital stays and to free up hospital beds for the use of patients with COVID-19. An approximately 30% reduction was observed, especially in breast and gastrointestinal cancers, although the decrease in the number of cancer screening tests performed are believed to be a factor affecting this outcome10. The factors affecting treatment modifications have included disease prognosis and stage, the expected benefit from treatment and toxicity risk, the patient's choice, age, performance status and the presence of comorbidities, as well as the capacity, resources and accessibility of the hospital16.

Evaluation of the right and left ventricular functions of patients that recovered from COVID‑19 at home

There are several reports in the literature on cardiac involvement in COVID-19 patients who are hospitalized. [...]the current research was designed to determine whether cardiac involvement occurred in COVID-19 patients at home. [...]different cardiovascular complications owing to COVID19, such as acute myocardial infarction, acute myocarditis, decompensated heart failure, and arrhythmia have been described in previous case series3. The purpose of our study was to compare echocardiographic findings (RV and LV function) in patients who had a positive PCR test for COVID-19 and finished their treatment at home to healthy individuals of similar age and gender. Individuals with ischemic heart disease, chronic obstructive pulmonary disease, myocarditis, valvular heart disease, pulmonary hypertension, malignancy history, heart failure, immunodeficiency, liver and kidney failure were excluded.

Lower-extremity nodules in a 2-year-old girl

According to her mother, the patient had no fever, upper respiratory symptoms, abdominal pain, vomiting, diarrhea, discolored urine, blood in stool, change in gait, weakness, or joint swelling. The results, completed 3 days after initial presentation, were the following: О Uric acid: 3.5 mg/dL (normal, 2.6-6.4 mg/dL) О LDH: 198 units/L (normal, 220-462 units/L) О CRP: 3.1 mg/L О M pneumoniae antibodies, IgM: 1234 U/mL (normal, < 770 U/mL) О Mpneumoniae antibodies, IgG: < 0.90 (normal < 0.90) О QuantiFERON-TB Gold: negative Differential diagnosis The initial differential diagnosis included several infectious and noninfectious etiologies that could account for the findings of the patient's skin lesions and laboratory results (Box). Erythema nodosum can be the first sign of a systemic illness such as tuberculosis and other bacterial or fungal infections, inflammatory bowel disease, sarcoidosis, or cancer, although in many cases, no cause of EN can be found.1,3-7 The most common cause of EN in children is idiopathic, followed by infection, sarcoidosis, and use of antibiotic drugs.1,6,8 Among infectious etiologies of EN in children, the most common are streptococcal pharyngitis, Yersinia, Mycoplasma, Chlamydia, histoplasmosis, coccidioidomycosis, and MycobacteriumA6-8 Diagnostic evaluation of EN includes a comprehensive history and physical exam as well as a complete blood cell count with differential, ESR, and CRP level.1,3 An individual patient's presentation might warrant further evaluation, including testing for streptococcal infection, chest ra- diography, stool cultures, or testing for infection with tuberculosis.1 Although EN is often self-limited, any identified underlying disorder should be treated appropriately. [...]a negative family history of irritable bowel disease and lack of gastrointestinal disturbances pointed away from Crohn disease or ulcerative colitis as possible etiologies.