Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center.

Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.

Extending the paleontology-biogeography reciprocity with SDMs: Exploring models and data in reducing fossil taxonomic uncertainty.

Historically, studies aimed at prospecting and analyzing paleontological and neontological data to investigate species distribution have developed separately. Research at the interface between paleontology and biogeography has shown a unidirectional bias, mostly focusing on how paleontological information can aid biogeography to understand species distribution through time. However, the modern suit of techniques of ecological biogeography, particularly species distribution models (SDM), can be instrumental for paleontologists as well, improving the biogeography-paleontology interchange. In this study, we explore how to use paleoclimatic data and SDMs to support paleontological investigation regarding reduction of taxonomic uncertainty. Employing current data from two neotropical species (Lagostomus maximus and Myocastor coipus), we implemented SDMs and performed model validation comparing hindcasts with dated fossil occurrences (~14k and ~20k years back present, respectively). Finally, we employed the hindcasting process for two South American fossil records of a misidentified species of caiman (Caiman sp.) to show that C. latirostris is the most likely species identity of these fossils (among four candidate species: C. latirostris, C. yacare, C. crocodilus, and Melanosuchus niger). Possible limitations of the approach are discussed. With this strategy, we have shown that current developments in biogeography research can favour paleontology, extending the (biased) current interchange between these two scientific disciplines.