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OBJECTIVES: Variation exists in the capabilities of electronic healthcare records (EHRs) systems and the frequency of their use by primary care physicians (PCPs) from different settings. We aimed to examine the factors associated with everyday EHRs use by PCPs, characterise the EHRs features available to PCPs, and to identify the impact of practice settings on feature availability. STUDY DESIGN: Cross-sectional study. METHODS: PCPs from 20 countries completed cross-sectional online survey between June and September 2020. Responses which reported frequency of EHRs use were retained. Associations between everyday EHRs use and PCP and practice factors (country, urbanicity, and digital maturity) were explored using multivariable logistic regression analyses. The effect of practice factors on the variation in availability of ten EHRs features was estimated using Cramer's V. RESULTS: Responses from 1520 out of 1605 PCPs surveyed (94·7%) were retained. Everyday EHRs use was reported by 91·2% of PCPs. Everyday EHRs use was associated with PCPs working >28 h per week, having more years of experience using EHRs, country of employment, and higher digital maturity. EHRs features concerning entering, and retrieving data were available to most PCPs. Few PCPs reported having access to tools for 'interactive patient education' (37·3%) or 'home monitoring and self-testing of chronic conditions' (34·3%). Country of practice was associated with availability of all EHRs features (Cramer's V range: 0·2-0·6), particularly with availability of tools enabling patient EHRs access (Cramer's V: 0·6, P < 0.0001). Greater feature availability of EHRs features was observed with greater digital maturity. CONCLUSIONS: EHRs features intended for patient use were uncommon across countries and levels of digital maturity. Systems-level research is necessary to identify the country-specific barriers impeding the implementation of EHRs features in primary care, particularly of EHRs features enabling patient interaction with EHRs, to develop strategies to improve systems-wide EHRs use.

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Background: Psychological therapies are increasingly delivered in community care settings. In existing literature, patient, disorder and service variables are known to have a significant impact on the recovery outcomes for patients undergoing psychological treatment in secondary care. The aim of this review is to establish which predictors have a significant impact on recovery from common mental health disorders in community settings. Methods: A systematic review of the literature was conducted according to PRISMA guidelines to identify variables with a predictive power on psychological therapy outcomes. We searched databases using key words and MeSH terms and a strict scoring system and bias check were used. Results: A total of 486 unique references were identified from the search. Overall, 19 papers met the inclusion criteria. These reported on a total of 34 778 patients from five countries in various community care settings. Predictive factors identified and found to be significant were initial severity and comorbid depression (11/19 studies), which negatively impacted outcome in all studies. Conclusions: We identified key predictors for recovery in a community settings from five countries. The evidence currently available for this setting is limited, so this review serves as a starting point to highlight key factors that warrant further investigation.

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BACKGROUND: In response to reported wound complication rates of 19% to 43% for traditional saphenous vein harvest, several minimally invasive vein harvest (MIVH) techniques have been developed. The purpose of this investigation is to determine the effectiveness of one such MIVH technology, the Genzyme SaphLITE Retractor System (Genzyme Biosurgery, Cambridge, MA). METHODS: Since May 2000, saphenectomy was undertaken in 305 coronary artery bypass graft (CABG) patients using SaphLITE in a prospective, nonrandomized trial at three centers. Patients were assessed for wound healing (ASEPSIS tool) and incisional pain (numeric scale) through the postoperative visit. Harvest times, incision lengths, and vein lengths were recorded. RESULTS: ASEPSIS indicated satisfactory healing in 96.0%. Infection rate was 1.3% with four patients requiring antibiotics and debridement of one incision. Of hospitalized patients, 85.4% had no or minimal affected leg pain. Additional mean data include: harvest time 43.4 +/- 17.6 minutes, incision number 3.0 +/- 1.2, incision length 2.9 +/- 1.4 cm, and vein length 46.0 +/- 15.2 cm. CONCLUSIONS: SaphLITE provides an effective alternative to traditional saphenous vein harvest, with improved wound healing, decreased pain, and acceptable harvest times.

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BACKGROUND: Clinical models of the human response to intense, acute stress have been limited to laboratory settings or cross sectional characterizations. As a result, data about the sensitivity of the human neuroendocrine activation to realistic stressors of varying magnitudes are limited. The U.S. Army survival course offers a unique opportunity to examine, in a controlled manner, the human response to acute, realistic, military stress. METHODS: Salivary data were collected in 109 subjects at baseline during four stress exposure time points and at recovery. Serum data was collected at baseline and recovery in 72 subjects and at baseline and during stress exposure in a subgroup of subjects (n = 21). RESULTS: Cortisol significantly increased during the captivity experience and was greatest after subjects' exposure to interrogations. Cortisol remained significantly elevated at recovery. Testosterone was significantly reduced within 12 hours of captivity. Reductions of both total and free T4 and of total and free T3 were observed, as were increases in thyrotropin. CONCLUSIONS: The stress of military survival training produced dramatic alterations in cortisol, percent free cortisol, testosterone, and thyroid indices. Different types of stressors had varying effects on the neuroendocrine indices. The degree of neuroendocrine changes observed may have significant implications for subsequent responses to stress.

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The prebiopsy evaluation of a child with a musculoskeletal neoplasm is the cornerstone for all subsequent treatment. A better understanding of the natural history of pediatric musculoskeletal tumors and an explosion in the development of sensitive new imaging modalities have significantly advanced the care of the child with a musculoskeletal pathologic condition. This article details the prebiopsy clinical and radiographic evaluation of the child or adolescent with a musculoskeletal neoplasm.

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Magnetic resonance imaging (MRI) is the only noninvasive method of defining a soft tissue tumor. The extent of the tumor and the question of involvement or noninvolvement of various adjacent tissues and structures can be determined. This information, determination of lymphatic and distant metastatic spread, is invaluable for staging and management of the disease. Whether or not the tumor type can be reliably determined, or even whether the malignant or benign nature of the tumor can be ascertained on MRI examination, is open to question. Review of the literature indicates proponents on both sides of the issue. This review illustrates the imaging features that are relevant to suggesting a histologic diagnosis, and the pitfalls that are encountered in trying to determine the malignancy or benignity of a lesion. The clinical significance of these determinations is also discussed.

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Irreducible dorsal dislocations of the distal interphalangeal joints of the fingers are uncommon injuries. They are almost always the result of an athletic injury. Although usually open, these can be subtle, closed injuries. Proper diagnosis requires clinical awareness and mandatory roentgenograms of all interphalangeal joint injuries.

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The changes seen in the periosteum and cortical bone are fundamental radiographic features of bone disease. The basic radiographic findings used for diagnosis of bone lesions (patterns of cortical destruction and of periosteal new bone formation) can be well identified with magnetic resonance (MR) imaging. The authors used comparative radiographic, computed tomographic, and MR images to illustrate patterns of periosteal reaction (simple, laminated, spiculated, Codman triangle), geographic and permeative cortical destruction, cortical erosion, cortical expansion and continuity, and intraosseous and extraosseous calcification. The only feature not well demonstrated by MR imaging is pattern or extent of soft-tissue calcification. Although MR images are not required for diagnosis of most peripheral bone lesions, when they are obtained, these fundamental diagnostic features should not be ignored.

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A case is presented in which the conventional radiograph was suggestive of avascular necrosis. This impression remained unchanged inspite of an MRI examination that was more suggestive or replacement of marrow. The diagnosis of ischemic necrosis was strongly supported by the patient having previously established avascular necrosis in the opposite hip. The gross pathologic specimen showed only necrotic tumor, which mimicked avascular necrosis on the plain film. The importance of placing proper confidence in the MRI findings is thus emphasized. A classification and brief description of the various types of chondrosarcoma are included in the Discussion.

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Tests on biopsies from HCC patients showed that 35% had integrated sequences of HBV DNA in their cell genomes. This was considerably more than controls but less than had been expected.

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Exertional leg pain may be secondary to a variety of problems. A systematic approach to patients with such pain allows early, accurate diagnosis. Noninvasive techniques allow the differentiation between claudication due to vascular disease and that due to spinal stenosis.

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A case of open dislocation of the interphalangeal joint of the thumb is presented. The anatomy of the injury is discussed as well as treatment options. In the 26-year-old male patient reported, hyperextension and rotation of the distal phalanx resulted in volar plate avulsion and ulnar displacement of the flexor pollicis longus. At operation the volar plate, which was blocking reduction, was repositioned through a dorsal incision as the flexor tendon was replaced in its correct position. Recovery has resulted.

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This paper describes the ultilization of a multiple family group as a novel crisis intervention technique for the families of hospitalized burn patients following a tank car explosion. The technique combined a multiple family group with an information group model using a multidisciplinary team of liaison psychiatrist, chaplain, social worker, and psychiatric nurse consultant. A brief dicussion of the theoretical model and literature is included, as well as an assessment of the group process, the perspective of the different disciplines involved, and a follow-up report.

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This article presents a case of fracture of the proximal tibial epiphysis. The diagnostic value of stress roentgenograms is discussed, featuring the use of tomography. Potential complications and treatment options also are discussed.

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There are two types of hypertrophic osteoarthropathy; (a) the secondary type, by far the most common and usually associated with bronchogenic carcinoma; and (b) the idiopathic type, a rare disorder occurring predominantly in males and not associated with any known disease process. Both may be associated with peculiar skin changes known as pachyderma. When idiopathic hypertrophic osteoarthropathy (IHOA) is associated with pachyderma it is called pachydermoperiostosis. In extremely rare instances, IHOA may occur without pachyderma. Three such cases are described.

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A patient was successfully charged with assault of a nurse on a Psychiatric Unit and was placed on probation for one year. The judge found her guilty despite the location of the incident and her 20-year history of previous psychiatric treatment, including 14 hospitalizations. Following this confrontation, the patient improved markedly in her behaviour and has continued to lead a more productive life without hysterical outbursts. It is concluded that proceeding with legal charges in such a situation is justifiable and can also be therapeutic.

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