Disparities in Breast Cancer Screening Uptake for Women With Mental Illness in the United Kingdom.

INTRODUCTION: Although there is evidence of disparities in breast cancer screening for women with mental illness in the U.S., there is a dearth of studies examining this association in the United Kingdom, where health care is provided free at the point of access. This population-based study examines the influence of mental illness, as assessed by the uptake of psychotropic medications, on breast screening uptake in the United Kingdom. METHODS: A cohort of 57,328 women identified from 2011 Census records within the Northern Ireland Longitudinal Study was followed through a single 3-year screening cycle (2011-2014) of the National Health Service Breast Screening Programme. Mental illness was identified by a receipt of psychotropic medication in the 3 months preceding screening invite. Individual- and household-level attributes were derived from Census records. Data were analyzed in 2019. RESULTS: More than a third of women received ≥1 prescription for psychotropic medication in the 3 months preceding screening invite. The odds of attendance in these individuals were reduced by 15% (OR=0.85, 95% CI=0.81, 0.88). Attendance was particularly low for women prescribed antipsychotics (OR=0.63, 95% CI=0.56, 0.70), anxiolytics (OR=0.61, 95% CI=0.57, 0.66), and hypnotics (OR=0.68, 95% CI=0.63, 0.72). CONCLUSIONS: These findings confirm the existence of significant disparities in breast screening uptake for women with mental illness. Targeted interventions are warranted to prevent avoidable breast cancer deaths in these individuals, especially given the increasing prevalence of mental illness.

Forensic 3D printing from micro-CT for court use- process validation.

Forensic application of 3D scanning and printing technology is gaining momentum with 3D printed evidence starting to be produced for court. However, the processes for creating these forensic 3D models requires still rigorous assessment to ensure they adhere to the relevant legal standards. Although, previous work has examined the accuracy of 3D prints created from medical grade Computed Tomography (CT), no such assessment has been carried out for Micro Computed Tomography (micro-CT) which offers superior resolution and the ability to capture forensically relevant injuries. This study aimed to quantify the error rates associated with forensic 3D printed models and toolmarks, created using three different printing technologies, based on micro-CT data. Overall, 3D printed models, based on micro-CT scans, replicate bone surface geometry to sub-millimetre accuracy (<0.62mm for overall shape and <0.36mm for toolmarks). However, there were significant differences between the printing technology employed (mean errors of -0.3%, -0.8%, and 0.7% for shape geometry and -0.8%, 14.1%, and 0.7% for toolmark geometry for Printers 1-3 respectively). Where possible, the authors recommend micro-CT imaging for producing forensic 3D printed bone models particularly when injuries are present.

A Holistic Multi-Scale Approach to Using 3D Scanning Technology in Accident Reconstruction.

Three-dimensional scanning and documentation methods are becoming increasingly employed by law enforcement personnel for crime scene and accident scene recording. Three-dimensional documentation of the victim's body in such cases is also increasingly used as the field of forensic radiology and imaging is expanding rapidly. These scanning technologies enable a more complete and detailed documentation than standard autopsy. This was used to examine a fatal pedestrian-vehicle collision where the pedestrian was killed by a van while crossing the road. Two competing scenarios were considered for the vehicle speed calculation: the pedestrian being projected forward by the impact or the pedestrian being carried on the vehicle's bonnet. In order to assist with this, the impact area of the accident vehicle was scanned using laser surface scanning, the victim was scanned using postmortem CT and micro-CT and the data sets were combined to virtually match features of the vehicle to injuries on the victim. Micro-CT revealed additional injuries not previously detected, lending support to the pedestrian-carry theory.

Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement.

BACKGROUND: Year-end clinic handoffs in resident continuity clinics are an important patient safety issue. METHODS: Intervention articles addressing the year-end resident clinic handoff were identified in a targeted literature search. These articles were reviewed and abstracted to summarize the current literature. On the basis of these reviews and consensus expert opinion, recommendations to improve year-end clinic handoffs were developed. RESULTS: Of 23 identified articles, 10 intervention articles in the fields of internal medicine, internal medicine-pediatrics, psychiatry, and family medicine were ultimately included. The additional 13 nonintervention studies were used as background material. There were 12 clinic handoff recommendations for improvement: (1) focus on patients most at risk during the handoff, (2) educate residents, (3) consider balancing caseloads for the residents, (4) prepare patients for the handoff and perform patient-centered outreach, (5) standardize a written method of sign-out and require verbal communication for a subset of patients, (6) use a standardized template or technology solution for the handoff, (7) identify specific tasks that require follow-up, (8) enhance attending supervision during the handoff, (9) make patient assignments clear after the handoff, (10) have patients establish care with the new provider as soon as possible after the handoff, (11) establish care with telephone contact prior to the first visit, (12) perform safety audits to ensure that sign-out occurs, patients receive appointments, no-shows are rescheduled, and task follow-up is completed. CONCLUSION: There is emerging evidence for interventions to improve year-end resident clinic handoffs, and the recommendations provided are a starting point to guide training programs.

The Med-Peds Hospitalist Workforce: Results From the American Academy of Pediatrics Workforce Survey.

OBJECTIVE: There is no published literature about the med-peds hospitalist workforce, physicians dually trained in internal medicine and pediatrics. Our objective was to analyze this subset of physicians by using data from the American Academy of Pediatrics (AAP) workforce survey to assess practice patterns and workforce demographics. We hypothesized that demographic differences exist between hospitalists and nonhospitalists. METHODS: The AAP surveyed med-peds physicians from the Society of Hospital Medicine and the AAP to define workforce demographics and patterns of practice. We compared self-identified hospitalists with nonhospitalist physicians on multiple characteristics. Almost one-half of the hospitalists self-identified as being both primary care physicians and hospitalists; we therefore also compared the physicians self-identifying as being both primary care physicians and hospitalists with those who identified themselves solely as hospitalists. RESULTS: Of 1321 respondents, 297 physicians (22.4%) self-reported practicing as hospitalists. Hospitalists were more likely than nonhospitalists to have been practicing<10 years (P<.001), be employed by a health care organization (P<.001), work>50 hours per week (P<.001), and see only adults (P<.001) or children (P=.03) in their practice rather than a mix of both groups. Most, 191/229 (83.4%), see both adults and children in practice, and 250/277 (90.3%) stated that their training left them well prepared to practice both adult and pediatric medicine. CONCLUSIONS: Med-peds hospitalists are more likely to be newer to practice and be employed by a health care organization than nonhospitalists and to report satisfaction that their training sufficiently prepared them to see adults and children in practice.

A multicenter intervention to improve ambulatory care handoffs at the end of residency.

BACKGROUND: Graduating residents transition their continuity clinic patients to junior colleagues every year, creating a vulnerable transition period for about 1 million patients nationally. OBJECTIVE: We examined a standardized, electronic template for handing off high-risk ambulatory patients by outgoing residents from 7 residencies within a large health care system, and compared handoff quantity and provider satisfaction for handoffs with and without that template. METHODS: Residents graduating in 2011 from 5 internal medicine, 1 family medicine, and 1 internal medicine-pediatrics residency programs in 1 health care system were randomized to a new electronic handoff process with a standardized intervention template or a free-text handoff. Expert reviewers independently evaluated all handoff notes, and providers were surveyed after follow-up appointments regarding use, helpfulness, and overall satisfaction with the handoffs. RESULTS: Fifty-two of 79 residents (66%) participated, performing 278 handoffs. Eighty-four patients (30%, 17 of 57) failed to follow up within the study period. For patients who followed up, providers read 61% (101 of 165) of the handoffs at the time of the visit. No significant difference existed between groups in the satisfaction of the follow up provider or the quality measure of the handoffs in our process. Expert agreement on which features make the handoff "helpful" was fair (κ  =  0.34). CONCLUSIONS: A standardized template did not improve handoff quantity or satisfaction compared with a free-text handoff. Practical handoff programs can be instituted into diverse residencies within a short time frame, with most residents taking part in creating the handoff formats.

Systematic training in internal medicine-pediatrics end of residency handoffs: residency director attitudes and perceived barriers.

BACKGROUND: It is unclear why systematic training in end-of-residency clinic handoffs is not universal. PURPOSES: We assessed Internal Medicine-Pediatrics (Med-Peds) residency program directors' attitudes regarding end-of-residency clinic handoff systems and perceived barriers to their implementation. METHODS: We surveyed all Med-Peds program directors in the United States about end-of-residency outpatient handoff systems. RESULTS: Program directors rated systems as important (81.5%), but only 31 programs (46.3%) utilized them. Nearly all programs with (29/31 [93.5%]), and most programs without systems (24/33 [72.7%]) rated them as important. Programs were more likely to have a system if the program director rated it important (p = .049), and less likely if they cited a lack of faculty interest (p = .023) or difficulty identifying residents as primary providers (p = .04). CONCLUSIONS: Most program directors believe it important to formally hand off outpatients. Barriers to establishing handoff systems can be overcome with modest curricular and cultural changes.

Hb Memphis [HBA2: c.70G>C (or HBA1)] in a Turkish child: a case report and comparison to Hb Q-Thailand (HBA1: c.223G>C).

Hb Memphis [α23(B4)Glu→Gln; HBA2: c.70G > C (or HBA1)] is a stable hemoglobin (Hb) variant caused by a substitution of glutamine for glutamic acid at residue 23 of the α2- or α1-globin chain. Heterozygous Hb Memphis has no known clinical or hematological effect, and all prior reports have resulted from observations in persons of African descent with sickle cell disease and an unusually mild clinical course. Family studies suggest that Hb Memphis may modulate sickling. Only brief characterizations of Hb Memphis trait in the absence of Hb S are present in the current literature. We report isolated Hb Memphis trait in Turkish individuals in whom the initial laboratory incorrectly identified the α variant as Q-Thailand [α74(EF3)Asp→His; HBA1: c.223G > C]. In one case, a heterozygous -3.7 kb α gene deletion was also present, which increased the variant Hb level to a percentage similar to that of the more common Hb Q-Thailand, which may have led to the misidentification. Herein, we discuss the characterization and comparison of these variants and underscore the necessity of confirming characterization by more than one method prior to assigning Hb variant identification.

Sectoral Economies, Economic Contexts, and Attitudes toward Immigration.

Do economic considerations shape attitudes toward immigration? In this article, we consider the relationship between economic interests and immigration preferences by examining how developments in individuals' sectors of employment affect these views. Using survey data across European countries from 2002 to 2009 and employing new measures of industry-level exposure to immigration, we find that sectoral economies shape opinions about immigration. Individuals employed in growing sectors are more likely to support immigration than are those employed in shrinking sectors. Moreover, the economic context matters: Making use of the exogenous shock to national economies represented by the 2008 financial crisis, we show that sector-level inflows of immigrant workers have little effect on preferences when economies are expanding, but that they dampen support for immigration when economic conditions deteriorate and confidence in the economy declines. These sectoral effects remain even when controlling for natives' views about the impact of immigration on the national economy and culture. When evaluating immigration policy, individuals thus appear to take into account whether their sector of employment benefits economically from immigration.

Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine-Pediatrics Program Directors.

BACKGROUND: End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices. OBJECTIVE: To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs. METHODS: We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients. RESULTS: Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001). CONCLUSIONS: Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

An intervention to improve ambulatory care handoffs at the end of residency.

INTRODUCTION: The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked. OBJECTIVES: To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs. METHODS: Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system. RESULTS: Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months. CONCLUSIONS: The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.