Identifying the problems, solutions, and challenges in referral writing: A Scoping Review

Abstract Background Both primary care physicians and other specialists are not satisfied with the quality and content of written communication between colleagues(1).  There is need of identifying the factors that lead to this dissatisfaction. Many of these are discussed in literature such as communication skills, teaching and assessment of referral writings to undergraduates, and lack of validated tool for evaluation of referral(2). This article is scoping review of literature for finding the problems, solutions, and challenges in referral writing. Methods The databases utilized for finding various referral systems are PubMed, ERIC, Pakmedinet and Google scholar. The article included in the study was 12 which were identified through PRISMA. These 12 articles were reviewed by two authors. (FA and TA) The first step was the application of Qualsyst criteria and then the two authors analyzed the final 12 articles for thematic analysis independently. Results The problems, solutions and challenges in referral writing were found after the thematic analysis by two authors. The multiple challenges regarding referral writing include the fact that details about the inadequate data written in referral letters, lack of teaching and learning strategies and lack of proper communication between physicians. There are many solutions like teaching and assessing the referral writing skills, introducing reflection and feedback to improve the skill among young doctors. Moreover, teaching the art of referral writing should include in the medical curriculum. Conclusion Referral writing is an important part of medical communication. A good quality referral will save time in management of patients. It will also enhance the outcome of patient management. There is need of teachings about communication skills in undergraduates and postgraduates students

Geochemistry and Petrographical Study of Langrial Iron Ore from Tethyan Hazara Area Pakistan, with Emphasis on its Economic Characterization and Depositional Setting

The Langrial iron ore of Hazara area has been studied in detail at five locations for its geochemistry, genesis and economic potential investigations. A maximum of thirty samples were collected from iron ore bodies at different localities of Bagnotar, Danna Noral, Tatti Maira, Najafpur and Jabri for detailed analysis. The thick bedded iron ore has been deposited in the form of unconformity at Cretaceous-Paleocene boundary sandwiched between Kawagarh and Hangu formations (i.e. Cretaceous-Paleocene boundary). At the base of Hangu Formation variable thickness of these lateritic beds spread throughout the Hazara and Kohat-Potwar plateau. These iron ore bodies are studied by X-Ray Diffraction technique (XRD), X-ray Fluorescence Spectrometry (XRF), Petrographic studies and Scanning Electron Microscope (SEM). This XRD analysis indicated that iron bearing minerals are hematite with intercalation of chamosite, quartz and a proportion of impurities having albite, illite-montmorillonite, kaolinite, calcite, dolomite and ankerite. The X-ray Fluorescence (XRF) results show that total Fe2O3 ranges from 30 to 50% having high silica, while alumina to silica ratio is less than 1. The petroghraphic studies revealed concentration of Langrial iron beds as oolitic hematite nodule having variable concentric to composite structure. A high energy shallow marine depositional environment was deduced for Langrial iron ore, as inferred from SEM and mineralogical data. The overall results show that Langrial iron ore is a low-grade iron ore with average Fe2O3 of 52%, and can be upgraded by applying modern mining techniques to fulfill steel requirements of the country

Regional Cerebral Oximetry as an Indicator of Acute Brain Injury in Adults Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation–A Prospective Pilot Study

Background: Regional cerebral oxygen saturation (rScO2) measured by near-infrared spectroscopy (NIRS) can be used to monitor brain oxygenation in extracorporeal membrane oxygenation (ECMO). ECMO patients that develop acute brain injuries (ABIs) are observed to have worse outcomes. We evaluated the association between rScO2 and ABI in venoarterial (VA) ECMO patients.Methods: We retrospectively reviewed prospectively-collected NIRS data from patients undergoing VA ECMO from April 2016 to October 2016. Baseline demographics, ECMO and clinical characteristics, cerebral oximetry data, neuroradiographic images, and functional outcomes were reviewed for each patient. rScO2 desaturations were defined as a >25% decline from baseline or an absolute value < 40% and quantified by frequency, duration, and area under the curve per hour of NIRS monitoring (AUC rate, rScO2*min/h). The primary outcome was ABI, defined as abnormalities noted on brain computerized tomography (CT) or magnetic resonance imaging (MRI) obtained during or after ECMO therapy.Results: Eighteen of Twenty patients who underwent NIRS monitoring while on VA ECMO were included in analysis. Eleven patients (61%) experienced rScO2 desaturations. Patients with desaturations were more frequently female (73 vs. 14%, p = 0.05), had acute liver dysfunction (64 vs. 14%, p = 0.05), and higher peak total bilirubin (5.2 mg/dL vs. 1.4 mg/dL, p = 0.02). Six (33%) patients exhibited ABI, and had lower pre-ECMO Glasgow Coma Scale (GCS) scores (5 vs. 10, p = 0.03) and higher peak total bilirubin levels (7.3 vs. 1.4, p = 0.009). All ABI patients experienced rScO2 desaturation while 42% of patients without ABI experienced desaturation (p = 0.04). ABI patients had higher AUC rates than non-ABI patients (right hemisphere: 5.7 vs. 0, p = 0.01, left hemisphere: 119 vs. 0, p = 0.06), more desaturation events (13 vs. 0, p = 0.05), longer desaturation duration (2:33 vs. 0, p = 0.002), and more severe desaturation events with rScO2 < 40 (9 vs. 0, p = 0.05). Patients with ABI had lower GCS scores (post-ECMO initiation) before care withdrawal or discharge than those without ABI (10 vs. 15, p = 0.02).Conclusions: The presence and burden of cerebral desaturations noted on NIRS cerebral oximetry are associated with secondary neurologic injury in adults undergoing VA ECMO

Referral writing: Consensus building on a tool for writing structured referrals

Competency in referral writing skill is needed by doctors for which they are never trained. Although there is a lot of work done about improvement of consultation letters still priority is not given. There must be a course for teaching and learning medical referral writing skills to students along with the assessment. Currently there is such tool to assess the way communication letter are written. An 18-point assessment scale has been developed through Delphi technique to increase the quality of referral letters. The objective of the present study was to design a structured Performa for writing referrals, validated by 7 participants using Delphi. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach’s alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Performa for writing referrals, with its inter-rater reliability calculated, is best for writing effective and structured referrals. The study further recommending training junior doctors in making proper referrals. MeSH Words: Referral and consultation, improving quality and referral, Checklists and referrals and consultation

Effect of growth temperature on the nanostructure and electrochemical properties of in-situ deposited WO3 thin films

Thin films of tungsten trioxide (WO3) have widespread applications such as in photocatalysis, electrochromism, photochromism, etc. Tuning the nanostructure of WO3 thin films has a notable impact on their electro/photocatalytic properties. In this work, WO3 thin films were prepared on FTO glass employing the in-situ hydrothermal method. Amongst other parameters of thin-film growth, the hydrothermal growth temperature is crucial toward WO3 thin film characteristics. The reaction temperature for the preparation of WO3 thin films in this study varied from 120 to 180 degrees C. XRD analysis revealed that WO3 thin films prepared at reaction temperatures of 120 (W120) and 150 degrees C (W150) have a hexagonal structure, whereas thin film prepared at 180 degrees C (W180) has a mixed hexagonal and monoclinic structure. The morphology of thin films changed with reaction temperature, as evidenced by FE-SEM analysis. Cyclic voltammetry analysis indicated that W120 exhibited fast Li+ ions insertion and extraction kinetics as compared to thin films synthesized at other temperatures. Finally, a correlation was made between the better electrochemical performance of W120 with its structure and morphology

Enhanced electrochemical performance of WO3 thin films prepared from polyvinyl alcohol-modified nanoparticle ink

Tungsten oxide (WO3) is a potential material in catalysis, sensors, electrochromic devices, etc. In this research work, porous WO3 thin films are prepared on FTO-glass employing spin coating of WO3 nanoparticle's ink modified with polyvinyl alcohol (PVA) in the concentration range of 0 to 25.0 wt%. This study explored the change in structure and morphology of WO3 thin films with varying PVA concentration in ink composition and their effect on the ability to intercalate and de-intercalate Li+ ions as a function of applied bias. The wettability of ink on FTO-glass improved by raising its PVA content. All WO3 thin films exhibited a monoclinic structure. Scanning electron microscopy images indicated that the porosity of WO3 thin films gradually increased with increasing PVA concentration up to 25 wt% but the thin film became highly nonuniform at a very high con-centration of additive. WO3 thin film prepared with ink having 10 wt% of PVA had optimum porosity and uniformity, therefore, yielded better electrochemical performance compared with all other samples. The addition of an optimum amount of PVA to ink is found to be an effective approach to modulating ink's characteristics and inducing porosity in thin films which eventually improves their redox reaction characteristics

Regulating the growth of WO3 thin films using ammonium acetate as structure directing agent

The optimization of morphology and structure of tungsten trioxide (WO3) needs to be performed to target some specific applications. In fields such as electrochromics and sensing, the study of electrochemical reaction kinetics is important as it defines the rate of reaction occurring on the WO3 surface. In the present study, WO3 thin films are grown on fluorine-doped tin oxide (FTO) glass by in-situ hydrothermal technique. To regulate the growth of the WO3 layer employing the hydrothermal method, ammonium acetate has been used as a capping agent (CA) and its molar ratio for tungsten, i.e., CA/W, was varied from 0 to 6. Cyclic voltammetry (CV) revealed that the thin film prepared with CA/W of 4 has improved Li+ ions intercalation/deintercalation which leads to fast reaction kinetics. Better electrochemical reaction kinetics in WO3 thin film with a CA/W ratio of 4 compared with the samples having CA/W of 0 and 2 is ascribed to its improved morphology and phase. X-ray diffraction and scanning electron microscopy analysis showed negligible thin film growth with a CA/W ratio of 6. Overall, WO3 thin film with a CA/W ratio of 4 showed excellent performance, making it a good candidate for electrochromics or other related applications