Twenty-Year Experience of a Single Referral Center on Pediatric Familial Mediterranean Fever: What Has Changed Over the Last Decade?

BACKGROUND/OBJECTIVE: Familial Mediterranean fever (FMF) is the most common autoinflammatory disease and is characterized by recurrent fever and serositis episodes. We aimed to share our 20-year FMF experience, clarify a phenotype-genotype correlation, and compare the characteristics and outcomes of pediatric FMF patients over the last 2 decades in this study. METHODS: This medical record review study included 714 pediatric FMF patients (340 females, 374 males), diagnosed by Tel Hashomer diagnostic criteria between January 2009 and January 2019 and followed up in our department. Demographic and disease characteristics, obtained from medical records of the patients, were compared between patients with M694V homozygosity and other genotypes and showed whether they were diagnosed before (n = 137) or after January 2010 (n = 577). χ2, Student t, and Mann-Whitney U tests were used to compare categorical and continuous variables between these groups. RESULTS: The most common symptoms were abdominal pain (92%), fever (89.5%), and arthralgia (64.5%). Mean ages at symptom onset and diagnosis were 5.16 ± 3.73 and 7.71 ± 3.87 years, respectively. M694V homozygosity was recorded in 111 patients (15.5%). Fever, arthralgia, arthritis, myalgia, erysipela-like erythema, colchicine resistance, and subclinical inflammation were more frequent, and mean disease severity score was higher in patients with M694V homozygosity. Fever, chest pain, and proteinuria were statistically more frequent in patients diagnosed before January 2010. Although M694V homozygosity rate was similar, patients diagnosed in the last decade had lower mean disease severity score. CONCLUSIONS: With this study, we speculate that although genotype and delay in diagnosis were similar, patients diagnosed in the last decade have a milder disease severity.

Prevalence of systemic lupus erythematosus in Spain: higher than previously reported in other countries?

OBJECTIVES: Prevalence of SLE varies among studies, being influenced by study design, geographical area and ethnicity. Data about the prevalence of SLE in Spain are scarce. In the EPISER2016 study, promoted by the Spanish Society of Rheumatology, the prevalence estimate of SLE in the general adult population in Spain has been updated and its association with sociodemographic, anthropometric and lifestyle variables has been explored. METHODS: Population-based multicentre cross-sectional study, with multistage stratified and cluster random sampling. Participants were contacted by telephone to carry out a questionnaire for the screening of SLE. Investigating rheumatologists evaluated positive results (review of medical records and/or telephone interview, with medical visit if needed) to confirm the diagnosis. To calculate the prevalence and its 95% CI, the sample design was taken into account and weighing was calculated considering age, sex and geographic origin. Multivariate logistic regression models were defined to analyse which sociodemographic, anthropometric and lifestyle variables included in the telephone questionnaire were associated with the presence of SLE. RESULTS: 4916 subjects aged 20 years or over were included. 16.52% (812/4916) had a positive screening result for SLE. 12 cases of SLE were detected. The estimated prevalence was 0.21% (95% CI: 0.11, 0.40). SLE was more prevalent in the rural municipalities, with an odds ratio (OR) = 4.041 (95% CI: 1.216, 13.424). CONCLUSION: The estimated prevalence of SLE in Spain is higher than that described in most international epidemiological studies, but lower than that observed in ethnic minorities in the United States or the United Kingdom.

Opportunities to diagnose fibrotic lung diseases in routine care: A primary care cohort study.

BACKGROUND AND OBJECTIVE: Temporal trends of healthcare use in the period before a diagnosis of pulmonary fibrosis are poorly understood. We investigated trends in respiratory symptoms and LR HRU in the 10 years prior to diagnosis. METHODS: We analysed a primary care clinical cohort database (UK OPCRD) and assessed patients aged ≥40 years who had an electronically coded diagnosis of pulmonary fibrosis between 2005 and 2015 and a minimum 2 years of continuous medical records prior to diagnosis. Exclusion criteria consisted of electronic codes for recognized causes of pulmonary fibrosis such as CTD, sarcoidosis or EAA. RESULTS: Data for 2223 patients were assessed. Over the 10 years prior to diagnosis of pulmonary fibrosis, there was a progressive increase in HRU across multiple LR-related domains. Five years before diagnosis, 18% of patients had multiple healthcare contacts for LR complaints; this increased to 79% in the year before diagnosis, with 38% of patients having five or more healthcare contacts. CONCLUSION: There are opportunities to diagnose pulmonary fibrosis at an earlier stage; research into case-finding algorithms and strategies to educate primary care physicians is required.

Age Differences in Suicide Risk Screening and Management Prior to Suicide Attempts.

OBJECTIVE: This study examined differences by age in suicide risk screening and clinical actions to reduce suicide risk among patients with visits to Veterans Health Administration (VHA) medical facilities in the year prior to an attempt. METHODS: Ninety-three VHA patient records were reviewed specific to the last visit before an attempt. Information was extracted regarding documentation of individual suicide risk factors and provider actions to reduce risk. RESULTS: The authors examined differences by patient age (≥50 versus 18-49). Older patients' medical records were less likely to have evidence of 1) screening for impulsivity and firearms access and 2) engagement in safety planning, referrals for mental health services, and consideration of psychiatric hospitalization. General medical providers were less likely to document these risk factors and action steps in comparison with mental health clinicians. CONCLUSION: Lethal means education and collaborative care are universal strategies that may improve identification of and lower suicide risk in older veterans.

The retropubic tension-free vaginal tape procedure-Efficacy, risk factors for recurrence and long-term safety.

INTRODUCTION: The retropubic tension-free vaginal tape has been the preferred method for primary surgical treatment of stress urinary incontinence and stress-dominated mixed urinary incontinence in women for more than 20 years. This study presents long-term safety and efficacy data and assesses risk factors for long-term recurrence. MATERIAL AND METHODS: In a case-series design we assessed a historical cohort of primary surgeries performed with the tension-free vaginal tape procedure in 596 women from 1998 to 2012 with follow up through 2015. Information from the medical records was transferred to a case report form comprising data on early and late complications and recurrence of urinary incontinence defined as bothersome stress urinary incontinence symptoms. All analyses were performed with SPSS using Pearson chi-square, survival and Cox regression analyses. RESULTS: After a 10-year follow up, mixed urinary incontinent women (hazard ratio 2.1, 95% confidence interval [CI] 1.4-3.0) had a significantly increased risk of recurrence of stress urinary incontinence symptoms compared with women with pure stress urinary incontinence as the indication for surgery. Overall cumulative cure rates after 1, 5 and 10 years were 92% (95% CI; 90%-94%), 79% (95% CI; 75%-83%) and 69% (95% CI; 63%-75%), respectively. Recurrent surgery (0.3%) and serious tape complications needing major surgical treatment (0.3%) were rare. Six patients (1.0%) had the tape cut due to urinary retention, and nine patients (1.5%) reported urinary retention more than 3 months after surgery. CONCLUSIONS: The tension-free vaginal tape procedure has a high long-term durability. Mixed urinary incontinence as an indication for surgery predicted long-term recurrence. Long-term complications were rare.

Colonoscopic perforations in the English National Health Service Bowel Cancer Screening Programme.

BACKGROUND: Perforation is the most serious adverse event associated with colonoscopy. In this study of data from the English National Health Service Bowel Cancer Screening Programme, we aimed to describe the presentation and management of perforations, and to determine factors associated with poorer outcomes post-perforation. METHODS: The medical records of patients with a perforation following the national screening colonoscopy were retrospectively examined. All colonoscopies performed from 02/08/2006 to 13/03/2014 were studied. Bowel Cancer Screening Centres across England were contacted and asked to complete a detailed dataset relating to perforation presentation, management, and outcome. RESULTS: 263 129 colonoscopies were analyzed, and the rate of perforation was 0.06 %. Complete data were reviewed for 117 perforations: 70.1 % of perforations (82/117) occurred during therapeutic colonoscopies; 54.9 % (62/113) of patients with perforations who were admitted to hospital and in whom data were complete underwent surgery; 26.1 % (30/115) of hospitalized patients left the hospital with a stoma and 19.1 % (22/115) developed post-perforation morbidity. Perforations not detected during colonoscopy were significantly more likely to require surgery (P = 0.03). Diagnostic perforations were significantly more likely to require surgery (P = 0.002) and were associated with higher rates of post-perforation morbidity (P = 0.01). At presentation, the presence of abdominal pain (P = 0.01), a pulse rate > 100 beats per minute (P = 0.049), and a respiratory rate > 20 breaths per minute (P = 0.01) were significantly associated with the patient having surgery. CONCLUSIONS: This is the largest retrospective observational case series in Europe to describe post-perforation presentation, management, and outcomes. We have confirmed that perforation leads to surgical intervention, stoma formation, and post-perforation morbidity. Perforations not recognized during the colonoscopy were significantly more likely to require surgery. Diagnostic perforations were at greater risk of requiring surgery and developing post-perforation morbidity.

Management strategies for patients with placenta accreta spectrum disorders who underwent pregnancy termination in the second trimester: a retrospective study.

BACKGROUND: The unique clinical features of pregnancy termination in the second trimester with concurrent placenta accreta spectrum (PAS) disorders place obstetricians in a complex and delicate situation. However, there are limited data on this rare and dangerous condition. The objective of this research was to investigate and evaluate the clinical management strategies of this patient group. METHODS: The medical records of patients who were diagnosed and treated in our hospital from December 2005 and December 2015 were retrospectively reviewed. RESULTS: A total of 29 patients were included in this analysis. A prenatal diagnosis was suspected in 8 (27.6%) patients, and the remaining 21 (72.4%) patients were diagnosed after pregnancy termination in the second trimester. In the subgroup with a prenatal diagnosis, a planned hysterotomy was performed in 7 patients who had total placenta previa and previous cesarean delivery. The remaining patient received medical termination. A subtotal hysterectomy was performed in 3 (10.3%) patients for life-threatening bleeding during hysterotomy, and the uterus was preserved with an in situ placenta in the remaining 5 patients. In the subgroup with a postnatal diagnosis, the implanted placenta remained partly or completely in situ in all 21 patients under informed consent. Ultimately, the implanted placenta remained partly or completely in situ in 26 (89.7%) patients in the two subgroups. With the application of adjuvant treatments, including uterine artery embolization and medication followed by curettage under ultrasound guidance, the implanted placenta was passed 76.6 (range: 19 to 192) days after termination. Uterus preservation was achieved in all 26 patients. The complications associated with conservative management included delayed postnatal hemorrhaging (2 cases, 7.7%), fever (6 cases, 23.1%), G1 transaminase disorder (4 cases, 15.4%), and myelosuppression (1 case, 3.8%). Seven women (26.9%) had a spontaneous pregnancy after conservative management, and no patient experienced recurrent PAS disorders. CONCLUSIONS: Leaving the implanted placenta in situ is the preferred choice for patients with PAS disorders who underwent pregnancy termination in the second trimester and desired fertility preservation. Multiple adjuvant treatment modalities, either alone or in combination, may help to promote the passing or absorption of the implanted placenta under close monitoring.

Pulmonary sequestration in adults: a retrospective review of resected and unresected cases.

BACKGROUND: Pulmonary sequestration (PS) is a form of congenital pulmonary malformation that is generally diagnosed in childhood or adolescence and usually resected when diagnosed. We aim to identify the clinical presentation and course of patients diagnosed to have PS during adulthood. METHODS: Using a computer-assisted search of Mayo clinic medical records, we identified adult patients with PS diagnosed between 1997 and 2016. Clinical and radiological data were collected including postoperative course for those who underwent surgical resection. RESULTS: We identified 32 adult patients with PS; median age at diagnosis was 42 years (IQR 28-53); 17 patients (53%) were men. The median sequestration size was 6.6 cm (IQR 4.4-9.3). The type of sequestration was intralobar in 81% and extralobar in 19%. The most common location was left lower lobe posteromedially (56%). Forty-seven percent of the patients presented with no relevant symptoms. The most common radiographic finding was mass/consolidation in 61% and the most common feeding artery origin was the thoracic aorta (54%). Surgical resection was performed in 18 patients (56%) and postoperative complication was reported in 5 patients (28%). There was no surgical mortality. Median duration of follow-up after diagnosis for unresected cases, most of whom were asymptomatic, was 19 months (IQR 4-26) with no complications related to the PS reported. CONCLUSIONS: Nearly one-half of adult patients with PS present with no relevant symptoms. The decision regarding surgical resection needs to weigh various factors including clinical manifestations related to PS, risk of surgical complications, comorbidities, and individual patient preferences.

The Efficacy of Neutral Position Beractant Administration in Neonates.

OBJECTIVE: The objective was to compare the efficacy and adverse effects of beractant administration in neonates via a single aliquot in a neutral position versus positioning the neonates on their left then right side and two aliquots administration. STUDY DESIGN: This was a retrospective cohort chart review of neonates who were diagnosed with respiratory distress syndrome and received beractant during two 15-month periods between 2013 and 2015 and 2015 and 2016 to compare the change in the fraction of inspired oxygen (FiO2) 1 hour after beractant administration. RESULTS: There were no differences in FiO2 1 hour after beractant between groups (p = 0.617). Adverse events and other comorbidities did not differ between the groups. CONCLUSION: Changing administration of beractant from two aliquots and positions to a neutral position resulted in no significant change in FiO2 and may be considered as an option for administration in neonates.

Intraductal Carcinoma of the Prostate on Diagnostic Needle Biopsy Predicts Prostate Cancer Mortality: A Population-Based Study.

BACKGROUND: Intraductal carcinoma of the prostate (IDC-P) is a distinct histopathologic feature associated with high-grade, advanced prostate cancer. Although studies have shown that IDC-P is a predictor of progression following surgical or radiation treatment for prostate cancer, there are sparse data regarding IDC-P on diagnostic needle biopsy as a prognosticator of prostate cancer mortality. MATERIALS AND METHODS: This was a population-based study of all prostate cancer patients diagnosed using needle biopsy and without evidence of systemic disease between 1991 and 1999 within a defined geographic region of Norway. Patients were identified by cross-referencing the Norwegian Cancer Registry. Of 318 eligible patients, 283 had biopsy specimens available for central pathology review. Clinical data were obtained from medical charts. We examined whether IDC-P on diagnostic needle biopsy was associated with adverse clinicopathological features and prostate cancer mortality. RESULTS: Patients with IDC-P on diagnostic needle biopsy had a more advanced stage and a higher Gleason score compared to patients without IDC-P. IDC-P was also associated with an intensively reactive stroma. The 10-year prostate cancer-specific survival was 69% for patients with IDC-P on diagnostic needle biopsy and 89% for patients without IDC-P (Log rank P-value < 0.005). The presence of IDC-P on diagnostic needle biopsy remained an independent predictor of prostate cancer mortality after adjustments for clinical prognostic factors and treatment. After adjustment for the newly implemented Grade Group system of prostate cancer, IDC-P showed a strong tendency toward statistical significance. However, IDC-P did not remain a statistically significant predictor in the multivariable analysis. CONCLUSION: IDC-P on diagnostic needle biopsy is an indicator of prostate cancer with a high risk of mortality. Accordingly, a diagnosis of IDC-P on needle biopsy should be reported and considered a feature of high-risk prostate cancer. Moreover, the association between IDC-P and reactive stroma provides evidence in support of the idea that stromal factors facilitate carcinoma invasion to the prostatic acini and ducts. Prostate 77:859-865, 2017. © 2017 Wiley Periodicals, Inc.

The Conversion of Planned Colonoscopy to Sigmoidoscopy and the Effect of this Practice on the Measurement of Quality Indicators.

OBJECTIVES: A cecal intubation rate (CIR) of >90% is a well-accepted quality indicator of colonoscopy and is consequently monitored within endoscopy units. Endoscopists' desire to meet this target may mean that incomplete colonoscopies are recorded as flexible sigmoidoscopies. The aim of this study was to examine whether the conversion of requested colonoscopies is a clinically significant phenomenon and whether this impacts upon the measurement of quality indicators. METHODS: A retrospective review of all flexible sigmoidoscopies performed between 1 January 2015 and 31 December 2015 at Nottingham University Hospitals, Sheffield Teaching Hospitals, and Cambridge University Hospitals was performed. Where a colonoscopy was requested but a flexible sigmoidoscopy performed, the patient's records and endoscopy reports were reviewed to determine whether this conversion was decided before the start of the procedure and documented. RESULTS: During the 12-month period, 6,839 flexible sigmoidoscopies were performed by 125 endoscopists. The original requests of 149 sigmoidoscopies could not be retrieved and were therefore excluded from this analysis. Of the 6,690 sigmoidoscopy requests reviewed, 2.8% (n=190) procedures were originally requested as a colonoscopy. On review of patient records, 85 conversions were appropriate according to pre-defined criteria. However, 105 conversions were deemed inappropriate, occurring in patients who had a valid documented indication for colonoscopy and had undergone full bowel preparation. The most common reasons cited included poor bowel preparation (n=37), technically challenging procedure (n=24), at the endoscopist's discretion based on clinical factors (n=21), and obstructing patology (n=8). A clear reason for conversion was not apparent in 11 cases. During the study period, 21,271 colonoscopies were performed and so conversions represent 0.45% of the total requests. When inappropriate conversions were included in individuals' performance data, 15 endoscopists fell to ≤90% target cecal intubation target. CONCLUSIONS: A small, but significant number of colonoscopies are converted to flexible sigmoidoscopies at the time of the procedure. This study demonstrates the conversion of colonoscopy to sigmoidoscopy as being a potential limitation of relying on CIR alone. Endoscopy units should consider monitoring the rate of inappropriate conversions to ensure quality.

Clinical Characteristics and Outcome of Hepatic Sarcoidosis: A Population-Based Study 1976-2013.

OBJECTIVES: Data on clinical manifestations and outcome of hepatic sarcoidosis are scarce. This study aimed to use a population-based cohort of patients with incident sarcoidosis to better describe the characteristics of hepatic sarcoidosis. METHODS: A cohort of incident cases of sarcoidosis in Olmsted County, MN, USA, from 1976 to 2013 was identified from the database. Diagnosis was verified by individual medical record review. Confirmed cases of sarcoidosis were then reviewed for liver involvement. Data on clinical manifestations, imaging study, liver biochemical tests, treatment, and outcome were collected. Cumulative incidence of cirrhosis adjusted for the competing risk of death was estimated. RESULTS: A total of 345 cases of incident sarcoidosis were identified. Of these, 19 cases (6%) had liver involvement (mean age 46.1 years, 53% female and 79% Caucasian). Most patients had asymptomatic liver disease and were discovered in pursuit of abnormal biochemical tests and imaging studies. Alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were elevated in the majority of patients (88 and 90%, respectively). Elevated transaminases were less common and less severe. About half of patients had abnormal imaging study with hypodense nodular lesions being the most common abnormality (six patients) followed by hepatomegaly (three patients). Liver biopsy revealed non-caseating granuloma in 88% (14 of 16 patients). A total of four patients developed cirrhosis. CONCLUSIONS: Involvement of the liver by sarcoidosis was seen in 6% of patients with sarcoidosis. The majority of patients were asymptomatic. Elevated ALP and GGT were the most common abnormal biochemical tests. Liver biopsy revealed non-caseating granuloma in almost all cases. Cirrhosis was seen in a significant number of patients. Generalizability of the observations to other populations may be limited, as the studied population was predominantly Caucasian. The prevalence of liver disease may be higher in more diverse populations.

Risk of Autoimmunity in EoE and Families: A Population-Based Cohort Study.

OBJECTIVES: Recent genome-wide association studies have suggested possible genetic associations between eosinophilic esophagitis (EoE) and genes associated with autoimmunity. No studies to date have looked at potential genetic association of EoE with specific autoimmune diseases by evaluating such diagnoses within family members. Investigate the risk of specific autoimmune disease within EoE probands and their extended family members. METHODS: The Utah Population Database offers a unique opportunity to link medical records from over 85% of Utah's population to genealogy records representing Utah. We searched for associations of specific autoimmune diseases in probands diagnosed with EoE and their extended family members (e.g., first cousins). Comparisons were made to age- and sex-matched controls and their respective families at a 5:1 ratio. RESULTS: Excess risk for multiple autoimmune conditions was detected in subjects with a diagnosis of EoE. Celiac, Crohn's, ulcerative colitis (UC), rheumatoid arthritis, IgA deficiency, CVID, multiple sclerosis (MS), and Hashimoto's thyroiditis were found at increased risk in first-degree relatives of EoE subjects. UC, systemic sclerosis, and MS had nominally significant associations within second-degree family members of EoE subjects; and, in reverse analysis, probands and their families with the above three conditions were at an increased risk for EoE suggesting shared genetic factors with EoE. CONCLUSIONS: Patients with EoE have an increased risk of multiple autoimmune diseases. Possible shared genetic etiologies were observed between EoE and UC, systemic sclerosis, and MS. Practitioners should be aware of these comorbid associations and query all EoE patients and family members for symptoms of these diseases.

Clinical predictors of diagnostic testing utility in the initial evaluation of chronic kidney disease.

AIM: No evidence-based approach to the evaluation of CKD has been established. We sought to identify clinical criteria to guide a rational diagnostic approach for the initial evaluation of CKD. METHODS: We conducted a retrospective cohort study of 1487 patients presenting for initial evaluation of CKD over 3 years (1/2010-1/2013) to academic nephrology clinics. We utilized the electronic medical record to determine tests ordered, abnormal results and testing that affected diagnosis and/or management. Diagnostic and management yield of testing was defined as the percentage of tests that affected diagnosis and/or management. High yield for a given test was defined as an increased likelihood of the test affecting diagnosis and/or management. RESULTS: We identified clinical criteria predictive of high yield for paraprotein-related testing (one of the following: history of monoclonal disease, high risk of CKD progression, hypercalcemia or haemoglobin < 10.6), and clinical criteria predictive of high yield for glomerulonephritis testing (one of the following: abnormal urine sediment, 3+ or greater hematuria or proteinuria > 500 mg/gm). A prior history of hydronephrosis and renal artery stenosis was predictive of high yield of abnormal renal ultrasound. Higher yield of testing was associated with higher risk progression categories for ANA, SPEP, urine sediment, calcium, PTH, haemoglobin, iron and ferritin. We estimate that initial CKD evaluation costs range from $28 to $109 million/year in US-Medicare expenditure. CONCLUSION: Numerous tests without significant clinical utility are obtained in initial CKD evaluation. Identifying criteria that can guide diagnostic testing may lead to a more informed and cost-effective approach to evaluation.

The utility of heart failure registries: a descriptive and comparative study of two heart failure registries.

BACKGROUND AND AIM: Registries are useful to address questions that are difficult to answer in clinical trials. The objective of this study was to describe and compare two heart failure (HF) cohorts from two Spanish HF registries. METHODS: We compared the RICA and EAHFE registries, both of which are prospective multicentre cohort studies including patients with decompensated HF consecutively admitted to internal medicine wards (RICA) or attending the emergency department (EAHFE). From the latter registry we only included patients who were admitted to internal medicine wards. RESULTS: A total of 5137 patients admitted to internal medicine wards were analysed (RICA: 3287 patients; EAHFE: 1850 patients). Both registries included elderly patients (RICA: mean (SD) age 79 (9) years; EAHFE: mean (SD) age 81 (9) years), with a slight predominance of female gender (52% and 58%, respectively, in the RICA and EAHFE registries) and with a high proportion of patients with preserved ejection fraction (58% and 62%, respectively). Some differences in comorbidities were noted, with diabetes mellitus, dyslipidaemia, chronic renal failure and atrial fibrillation being more frequent in the RICA registry while cognitive and functional impairment predominated in the EAHFE registry. The 30-day mortality after discharge was 3.4% in the RICA registry and 4.8% in the EAHFE registry (p<0.05) and the 30-day readmission rate was 7.5% in the RICA registry (readmission to hospital) and 24.0% in the EAHFE registry (readmission to emergency department) (p<0.001). CONCLUSIONS: We found differences in the clinical characteristics of patients admitted to Spanish internal medicine wards for decompensated HF depending on inclusion in either the RICA or EAHFE registry.

[Analysis of the results of a questionnaire survey among the patients presenting with nasal cavity and paranasal sinuses diseases concerning organization and quality of specialized medical assistance].

The objective of the present study was to evaluate the influence of the medico-social factors on the development of nasal cavity and paranasal sinuses diseases and satisfaction of the patients with the quality of the provided specialized medical assistance. The approaches to the treatment of such patient at the pre-hospital and hospital levels are discussed.

Reasons for disagreement regarding illnesses between older patients with multimorbidity and their GPs - a qualitative study.

BACKGROUND: Chronic conditions are the most common themes in doctor-patient communication, especially for older patients with multimorbidity and their GPs. Former quantitative studies identified a variety of socio-demographic and health-related factors which were associated with the (dis-)agreement between medical records and patient self-reported diseases. The aim of this qualitative study was to identify reasons for disagreement regarding illnesses between patients and their GPs. METHODS: We conducted three focus groups with GPs (n = 15) and three focus groups with multimorbid patients aged 65 to 85 (n = 21). The participants were recruited from the MultiCare Cohort Study. Focus groups were audiotaped and transcribed verbatim. The transcripts of the focus groups were analysed using the qualitative content analysis according to Mayring. Categories were determined deductively and inductively. RESULTS: The analysis revealed seven themes concerning reasons for disagreement regarding illnesses between patients and their GPs: problems with communication and cooperation between health care professionals, disease management by the GP and the patient, the documentation behaviour of the GP, communication challenges between GP and patient, differences in the understanding of a disease between GP and patient, the prioritization and rating of diseases by GP and patient and obliviousness, repression and avoidance by the patient. CONCLUSIONS: For older patients with multimorbidity, our study demonstrated that there is a need to enhance the cooperation between GPs, specialists and outpatient care, a demand to improve doctor-patient communication and a need for interventions to increase patients' knowledge of diseases.

Health care contacts in the year before suicide death.

BACKGROUND: Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples. OBJECTIVE: To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed. DESIGN: Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states. PARTICIPANTS: In all, 5,894 individuals who died by suicide, and were health plan members in the year before death. MAIN MEASURES: Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site. KEY RESULTS: Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means. CONCLUSIONS: This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Heterotaxy syndrome: impact of ventricular morphology on resource utilization.

Patients with heterotaxy syndrome (HS) have significant cardiac and extracardiac anomalies that impact outcome. To improve the management of this complex patient population, we performed a comprehensive analysis of their anatomic and clinical features along with an evaluation of resource utilization data. The objectives were to describe anatomic and clinical features of patients with HS syndrome treated at a single center from 1992 to 2011 focusing on the impact of ventricular morphology (univentricular [UV] vs. biventricular [BV]) on clinical outcomes and resource utilization. Clinical and echocardiographic data from patients with HS were abstracted from medical records. Health care costs were indexed to inflation. Seventy-eight patients were identified with HS ranging in age from 1 day to 29 years old. UV morphology was present in 46 patients (59 %), most commonly with right-ventricular dominance (36 of 46). The presence of extra cardiac anomalies did not differ between the UV and BV groups (82 vs. 78 %) nor did morbidities, such as need for enteral tube feedings (47 vs. 25 %) or pacemaker placement (24 vs. 25 %). Mortality was 28 % in the entire cohort: 39 % in univentricuar patients versus 10.5 % in those with biventricular anatomy. Hospital length of stay for medical illnesses was similar in both groups, but length of stay after surgery was significantly longer in UV than BV patients. Among survivors, UV patients had greater median hospital costs (TeX 67,732, p < 0.001), but when this was adjusted for mortality and variable follow-up, there were no differences in health care costs within the first year of life. Significant health care dollars are used to manage children with HS, the majority of which involve expenses related to surgical care. Although patients with biventricular morphology have better survival, morbidity and resource utilization are similar to those for UV patients especially within the first year of life.

[The influence of patient compliance with antiangiogenic therapy on its efficacy for neovascular age-related macular degeneration].

PURPOSE: To study the level of patient compliance with Ranibizumab therapy and affecting factors. MATERIAL AND METHODS: Medical records of 76 patients aged from 50 to 86 years (mean age 70.7 +/- 9.5 years) who underwent Ranibizumab treatment for neovascular age-related macular degeneration (AMD) during 2010-2014 were used. Demographic data, visual acuity, optical coherence tomography results were analyzed. Surgical interventions, regularity of postoperative follow-up and its outcomes were also taken into consideration. RESULTS: The results showed high efficacy and safety of Ranibizumab therapy, though patient adherence varied significantly during the treatment course. More than 90% of patients demonstrated strong adherence to treatment in the phase of stabilization. During the follow-up period on a monthly basis and in the phase of maintenance therapy the level of compliance was 48.6% and 63.2% correspondingly. It is found that patient adherence depends on the duration of treatment, visual acuity of the contralateral eye, and functional results of the initial stage of the treatment (phase of stabilization). Four clinical examples are provided to illustrate the correlation between treatment efficacy and compliance. CONCLUSION: Patient compliance with Ranibizumab antiangiogenic therapy for neovascular AMD improves its efficacy, ensuring maximum increase of visual acuity in the phase of stabilization and functional stability in the phase of maintenance therapy. Monthly performed follow-up allows early detection of disease recurrence and timely recommencement of the treatment.