EP22.08: First trimester detection of abnormally invasive placenta: case series in a primary referral centre

This study aims to analyze the satisfaction levels of outpatients participating in Indonesia's national health insurance (JKN) under its tiered referral system. The research objective is to assess patient satisfaction at Dr. Slamet Regional Public Hospital, a primary referral center, across six key dimensions. A mixed-methods approach was employed, using surveys with 105 outpatients and in-depth interviews with hospital personnel. The findings reveal an overall patient satisfaction level of 74.01%, classified as “good.” Medical services received the highest satisfaction score (76.62%), while cost perception was the lowest (69.14%). Although clinical care is highly rated, the study identifies significant administrative complexity and long waiting times as primary sources of patient dissatisfaction. The main implication is that while the JKN program succeeds in delivering quality medical care, the patient experience is significantly hampered by bureaucratic inefficiencies. Practical improvements should focus on streamlining administrative procedures and optimizing patient flow to enhance overall satisfaction.

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. In advanced disease, mitotane given as monotherapy or combined either with etoposide, doxorubicin, and cisplatin or with streptozotocin is the recommended first-line therapy. However, many patients have progressive disease despite treatment with these regimens. Our objective was to evaluate the efficacy of the epidermal growth factor receptor inhibitor erlotinib plus gemcitabine as salvage therapy in ACC patients with very advanced ACC. The study consisted of case series collected from different centers (primary care and referral centers) in Germany in 2006-2007. Patients registered with the German ACC Registry with progressive ACC after two to four previous systemic therapies were offered treatment with erlotinib and gemcitabine. Oral erlotinib (100 mg/d) was administered on a daily basis and gemcitabine (800 mg/m(2)) iv every 14 d. We evaluated tumor response according to response evaluation criteria in solid tumors (RECIST) criteria after 12 wk of treatment. Ten patients have been treated with erlotinib and gemcitabine. Only one in 10 patients experienced a minor response (progression-free survival 8 months), whereas eight patients had progressive disease at the first staging. One patient had to stop therapy after the first administration of gemcitabine due to cerebral seizure. Nine of 10 patients had died after a median of 5.5 months after treatment initiation. In addition to the seizure, one patient experienced severe pneumonia (grade III), and in one, gemcitabine administration had been delayed due to prolonged neutropenia. All other adverse events were mild (grade I-II). Salvage chemotherapy using erlotinib plus gemcitabine has very limited to no activity in patients with very advanced ACC.

By a simple self-administered hand test, hand handicap was revealed in 689 out of a population of 5262 individuals aged 40-70 years. Subsequent medical examination showed inflammatory hand disease in 119, 67 of whom had previously been in contact with the public health service at some level because of hand dysfunction. These 67 patients formed the material for our study, whose purpose was to analyse the distribution, treatment and follow-up of patients with inflammatory joint disease on different health care levels. In primary health care, rheumatoid arthritis (RA) was found to be underreported. For half the cases the interval between onset of disease and assessment by a rheumatologist exceeded 5 years, and follow-ups were few and far between. In the referral centres, RA cases were dealt with more adequately. The prevalence of definite and probable RA was found to be 0.7 and 0.4%, respectively.

BackgroundCancer is the second cause of death in children and its diagnosis can be difficult, due to the presence of vague and non-specific symptoms. The primary care pediatrician is often involved in the diagnostic process, but no longer in child care once the treatment started. Care models involving both primary care pediatricians and oncologic referral centre highlighted a higher family satisfaction when they worked together. We conducted a survey on primary care pediatricians involved in childhood cancer in order to describe the actual situation.MethodsWe conducted a retrospective survey enrolling primary care pediatricians from a north-eastern area of Italy. They received a questionnaire that consisted in two parts: the first one aimed to assess the physician’s seniority and experience and the second one pertained to each case of cancer and explored the relationship between the pediatrician, the family and the referral centre, and pediatricians degree of satisfaction and emotional impact.ResultsWe obtained data from 79 pediatricians who described 150 cancer cases. In 99 cases the primary care pediatrician had visited the child at the onset of symptoms and had referred him to the hospital. In 89 cases, he understood the severity of the disease. In 53.3% of cases the pediatrician was informed by the referral centre. The relationship between the pediatrician and child’s family improved in 38% of cases and this was related with their participation to the multidisciplinary meetings on child health.ConclusionsPrimary pediatricians’ sharing in the management of their patients with cancer was not satisfactory. Development of specific protocols targeted to an integrated care is needed to increase primary pediatricians’ involvement and families’ satisfactions.

To assess the sensitivity, specificity, and predictive value of ultrasonography in patients with blunt abdominal or thoracic trauma in regard to the indication for immediate operation, delayed abdominal exploration, or conservative treatment. A retrospective study was conducted after consecutive sampling of 1151 patients in a nonrandomized control trial. The study was conducted at the University Hospital of Innsbruck (Austria), which serves as a general community hospital and a major primary care and referral center. All patients with blunt abdominal or thoracic trauma with or without polytraumatization were eligible for the study; a total of 1151 patients were observed from 1980 to 1990. According to the ultrasonographic findings, patients were divided into three groups: immediate operation, primary conservative treatment, and conservative treatment (normal ultrasonographic findings). Ultrasonography was repeated when the clinical findings or laboratory test results showed the development of intra-abdominal hemorrhage or signs of organ laceration. Ultrasonography in the emergency department or intensive care unit. Conservative or operative treatment based on ultrasonographic and clinical findings. Ultrasonography showed a sensitivity of 99%, a specificity of 98%, a positive predictive value of 0.97, and a negative predictive value of 0.99 in regard to the indication for surgery in cases of blunt abdominal or thoracic trauma. Ultrasonography is not reliable in patients with intestinal perforation and large retroperitoneal hematomas. Ultrasonography saves time and money, can be performed in the emergency department, shows high sensitivity and specificity, and is the method of first choice in the evaluation of blunt trauma.

We compared the treatment policy for patients with epilepsy in six Dutch cities, comprising 302, 149 inhabitants, with the treatment policies of a secondary referral center (a university hospital) and tertiary referral centers (outpatient departments of epilepsy centers). By comparing the prevalence of individuals receiving antiepileptic drugs in the six cities with the epidemiologic data for epilepsy in Rochester, Minnesota, we concluded that prescription data offer a suitable means by which to estimate the prevalence of epilepsy in a community. To compare prescriptions in cases of polytherapy, we normalized data by using defined daily doses published by the WHO Collaborating Center for Drugs Statistics Methodology and the Nordic Council on Medicines and concluded that the defined daily doses of antiepileptic drugs should be further elaborated. There is a need to obtain complete dose-response curves of equivalent antiepileptic drugs in humans. The trend of drugs use found in the six cities, the university hospital, and the epilepsy centers is, however, in accord with the expectations regarding primary, secondary, and tertiary referral centers.

Comparison of avian and nonavian hyaluronic acid in osteoarthritis of the knee Robert J Petrella, Anthony Cogliano, Joseph DecariaFaculties of Medicine and Health Sciences, University of Western Ontario, London, ON, CanadaBackground: Hyaluronic acid (HA) in knee osteoarthritis (OA) has been shown to be efficacious and safe, but long-term follow up and head-to-head comparison of products, in particular those of avian versus those of nonavian origin, are lacking.Objective: The objective was to compare the efficacy and safety of avian and nonavian origin HA in the treatment of knee OA during a long-term follow-up.Methods: Patients were enrolled on a consecutive basis from all referrals received from 1997 to 2007 at a large primary care referral center in London, Canada. Patients were allocated to commercially available avian and nonavian origin HA based on their own preference for product. Patients were not randomized to therapy nor did the referral center advocate one product versus another. During the period of investigation, three nonavian and two avian products were available in Canada. Injections were given once weekly over three weeks (one series) using a lateral approach. Assessments included body mass index, numbers of medications, number of chronic diseases, duration of knee OA at presentation, visual analog scale (VAS) score (0–10 cm) for rest and weight-bearing pain, patient satisfaction with treatment (5-point categorical scale), numbers of HA series to the point of analysis, previous intra-articular treatment prior to first injection series, adverse events, serious adverse events, and self-payment versus third party payment. Following the first injection series, patients returned to the clinic of their own volition. Inclusion for a second and subsequent injection series was based on a patient request but also requirement of a resting VAS score > 4.5 cm. All patients had radiographic evidence of at least grade 1 OA. Patients who crossed over to alternate avian or nonavian product were not included in the analysis following crossover. Patients could switch within class of HA product. Differences were compared using analyses of variance and were considered significant at P < 0.05.Results: Four thousand four hundred twelve patients were evaluated for inclusion. Avian or nonavian HA were received by 1,726 versus 1,971 patients, respectively. There were no significant differences in demographic characteristics between groups. There were no differences in reduction of resting pain between groups between the first and 10th consecutive series of HA injections; however, there was a significantly greater improvement in weight-bearing pain (P < 0.01) favoring nonavian HA after the 7th series. There was also a significantly greater number of adverse events (4.8% versus 1.7%; P < 0.01) in the avian- compared to nonaviantreated patients.Conclusions: Both avian and nonavian HA improve pain in patients with osteoarthritis of the knee. Some difference in weight-bearing pain favoring nonavian HA was seen later in the treatment cycle while a significantly greater number of adverse events was observed in avian HA-treated patients.Keywords: hyaluronic acid, osteoarthritis of the knee, avian and nonavian

BackgroundChildren and adolescents diagnosed with cancer often experience psychological distress, encompassing anxiety, depression, and post-traumatic stress disorder (PTSD). This study aimed to evaluate the prevalence of these conditions among Omani children and adolescents diagnosed with cancer, alongside identifying contributing factors.MethodsA prospective cross-sectional study was conducted from October 2021 to June 2023 among a cohort of Omani children and adolescents (6–18 years old) diagnosed with cancer at three primary cancer referral centres in Oman. Validated Arabic-language versions of the Screen for Child Anxiety Related Disorders, the Center for Epidemiologic Studies Depression Scale for Children, and the Impact of Event Scale-Revised instruments were used to assess symptoms of anxiety, depression, and PTSD, respectively. An initial assessment (T1) was undertaken within the first 3 months of diagnosis, followed by a second assessment (T2) 3–6 months later.ResultsOf 113 eligible participants, 101 agreed to participate in the study (response rate: 95.6%), with 92 (91.0%) completing both assessments and included in the final analysis. Prevalence rates of anxiety, depression, and PTSD decreased from 43.5%, 56.5%, and 32.6%, respectively, at T1, to 38.0%, 35.9%, and 23.9% at T2. All average scores were below diagnostic cut-off points, except for the depression score at T1. Anxiety and depression scores decreased significantly (p = 0.043 and 0.001, respectively) between T1 and T2, as did the overall prevalence of depression (p = 0.004). At T1, linear regression analysis showed significant correlations between anxiety scores and the child’s age and PTSD score (p < 0.05); these variables were also correlated with depression scores (p ≤ 0.001). At T2, significant correlations were observed between anxiety scores and the child’s age and PTSD scores (p < 0.001). At both T1 and T2, anxiety, depression, and PTSD scores remained significantly correlated (p < 0.001).ConclusionsOmani children and adolescents recently diagnosed with cancer exhibit a high prevalence of anxiety, depression, and PTSD over time. Age-appropriate communication, ongoing support, and mental health services are recommended to help this patient group cope with their diagnosis and manage their emotional wellbeing. There is a need for future research to determine the effectiveness of specific psychological interventions in reducing the frequency of these disorders.

During this pandemic, dermatological infusion centers were partially unavailable, suspended or even reconverted to guest COVID‐19 patients, consequently infliximab (IFX) infusions became challenging for their both logistic arrangement and also for patients' COVID‐19 phobia. This 48 weeks follow‐up retrospective observational study included 37 PsO patients that underwent IFX SB2 during pandemic in two primary dermatological referral centers. In 23 (62.1%) we had to switch from IFX to other biologics, not motivated by adverse reactions, contraindication or even loss of response but only to pandemic related conditions. Nine patients underwent interclass switching and 15 underwent intraclass switching; interestingly 2 patients that underwent adalimumab SB‐5 switched back to IFX. Interclass switching was privileged in elder patients and smokers. All patients at week 48 achieved PASI 100. Intra‐ and interclass switchings are both safe and effective strategies in psoriatic patients with COVID‐19 phobia and/or difficulties to undergo infliximab infusions.

Purpose: To investigate the mortality, quality of life and functional limitations of intensive care unit (ICU) patients with and without joint contractures 3.3 years after discharge from the hospital. Methods: 155 consecutive patients admitted to a primary care referral centre ICU for 2 or more weeks with information on joint range of motion formed a retrospective cohort. The EuroQol and a Joint Contracture Questionnaire were administered to the cohort survivors. Results: Fifty patients returned the questionnaires, 57 did not return the questionnaire, and 48 were deceased. The patients who had died presented significantly more joint contractures in the ICU than the respondents and the non-respondents (p = 0.003 and p = 0.006, respectively). More respondents who reported limitations in their mobility on the EuroQol had joint contractures in ICU 13/18 (72.2%) compared to respondents who did not have contractures 7/21 (33.3%; p = 0.02). Conclusions: Joint contractures in ICU were associated with higher mortality. Patients who spent 2 weeks or more in ICU and developed joint contractures identified more difficulty with mobility 3.3 years after discharge; joint contractures may impose irreversible disability. A strategy to identify and treat joint contractures in ICU may prevent long-term functional limitations.Implications for RehabilitationThe presence of joint contractures was associated with higher mortality more than 3 years after discharge.Joint contractures that developed in ICU were associated with disability for mobility more than 3 years after ICU discharge.Monitoring, detection and early rehabilitation may be critical in treating joint contractures before they become irreversible.These results support prospectively tracking contractures of large joints in the continuum from ICU to hospital to home.

Benefit-risk communication in paediatric imaging: What do referring physicians, radiographers and radiologists think, say and do?

ObjectivesThe objectives are to investigate radiology practitioners’ and radiographers’ radiation dose awareness and use of referral guidelines for paediatric imaging examinations.MethodsA prospective cross-sectional survey was conducted amongst radiology practitioners and radiographers working at a primary paediatric referral centre in Malta. Part of the survey asked participants to indicate the typical effective dose (ED) for several commonly performed paediatric imaging examinations, answer five true-false statements about radiation protection principles, and specify their use of referral guidelines for paediatric imaging.ResultsThe return of 112 questionnaires provided a response rate of 66.7 %. Overall, imaging practitioners demonstrated poor awareness of radiation doses associated with several paediatric imaging examinations, with only 20 % providing the correct ED estimate for radiation-based examinations. Nearly all participants had undertaken radiation protection training, but the type and duration of training undertaken varied. When asked about the use of referral guidelines for paediatric imaging, 77.3 % claimed that they ‘did not’ or ‘were not sure’ if they made use of them.ConclusionsPoor awareness of radiation doses associated with paediatric imaging examinations and the non-use of referral guidelines may impede imaging practitioners’ role in the justification and optimisation of paediatric imaging examinations. Education and training activities to address such shortcomings are recommended.Key Points• Imaging practitioners demonstrated poor radiation dose awareness for 5 paediatric imaging examinations.• Most radiology practitioners and radiographers were ‘not sure’ or ‘did not’ use referral guidelines.• Imaging practitioners generally considered previously undertaken paediatric imaging examinations.• Some imaging practitioners had not undertaken training in radiation protection for 10 years.• Training activities to address imaging practitioners’ poor radiation dose awareness are encouraged.

ObjectivesTo evaluate if pre-pregnancy body mass index (BMI) determines blood pressure throughout pregnancy and to explore the role of gestational weight gain in this association. In addition, the effects of...

Context: This was a comparative prospective study. Aims: (1) To characterize acoustic reflex decay (ARD) and acoustic reflex latency threshold (ARLT) profiles in cerebellopontine angle (CPA) tumors. (2) To correlate ARD and ARLT test results with the type, size, and extent of tumors. Study Design: Comparative prospective study. Setting: Primary versus Tertiary referral center. Subjects: The clinical group comprised 98 patients with CPA tumor and the control group comprised 100 normal hearing subjects. Subjects and Methods: ARD and ARLT were estimated at 500 Hz and 1000 Hz both ipsilaterally and contralaterally for both the groups. Statistical Analysis Used: Statistical analysis for clinical group versus control group was carried out using analysis of covariance for age and gender covariates. For discrete clinical groups, analysis of variance followed by post hoc (Turkey) test was used. An independent sample t-test was used for the statistical analysis of tumor ear versus nontumor ear. Results: Test results indicated that the proportion of ears with abnormal reflex decay (0%–25%) was less compared to those with normal findings (75%–100%) in the patient group reflecting the poor efficacy of ARD to identify the presence of CPA tumors. Statistical analysis for ARLT was possible mainly for nontumor ear stimulation and it did not give any clear indications regarding the presence of brain stem compression. Conclusions: In the present study, an estimation of ARD and ARLT did not appear to be useful indices for CPA tumor identification.

This study aimed to assess the cascade of care in the reduction of mother-to-child HIV transmission in the states of Amazonas, Ceará, Espírito Santo, Rio de Janeiro, and Rio Grande do Sul and the Distrito Federal, Brazil, using data from the Brazilian Information System on Diseases of Notification (SINAN). From 2007 to 2012, there was an increase (from 7.3% in Distrito Federal to 46.1% in Amazonas) in intra-gestational detection of HIV in 5 states, with a 18.6% reduction in Rio de Janeiro. Fewer than 90% of the women received antiretroviral therapy during their prenatal care, including those that already knew they were HIV-positive. The elective cesarean rate was low. The AIDS detection rate in children under 5 years as a proxy for mother-to-child HIV transmission showed a reduction of 6.3% from 2007 to 2012, and was highest in Rio Grande do Sul (50%), the state with the highest rates in the period, while Espírito Santo showed the highest increase (50%). Evaluation of the cascade of HIV care in pregnant women identified flaws in all the points. A link is needed between primary care and referral centers for HIV/AIDS, organizing care for the family and better outcomes for the children.