Common Indication For Referral Research Articles

Gated SPECT myocardial perfusion imaging in patients referred with isolated complaints of Dyspnea

Background: Dyspnea is a common indication for referral for cardiovascular stress testing. We sought to characterize the utility of gated SPECT stress perfusion imaging in patients referred because of a chief complaint of dyspnea. In this group comorbidities included cad 22%, hyperternsion 74%, hyperlipidemia 49%, diabetes 38%, chf 20%, copd 17%. Methods: a total of 89 consecutive (66 ± 13 yrs) patients from a total referral population of 870 pts were referred for a chief complaint of dyspnea. Patients underwent dual gated SPECT myocardial imaging utilizing either an exercise protocol or an abbreviated, 4 minute adenosine infusion (140 ug/kg/min; 4 min; 1 mph walk) with simultaneous low level exercise. Coronary artery disease was determined by calculation of summed stress scores (SSS) using the conventional, previously validated 17 segment (0–4 perfusion scale) model with a SSS>4 used as a threshold for an abnormal scan. Results: Perfusion defects diagnostic for CAD were present in 22% of the patients presenting with dyspnea and were of varying degree of severity. While mean systolic function for the overall group was normal (EF=52±15%), compared to patients with a negative nuclear scan (SSS<4) those whose study was positive (SSS≥4) had a significantly lower ejection fraction (45±13%; 54±15%;p=0.02). Multiple logistic regression analysis revealed that only age (OR=1.097; CI=1.03–1.17; p=0.008) and gated stress EF (OR=0.932 ; CI=0.88–0.98;p=0.004) were associated with presence of CAD by nuclear imaging. Neither a prior history of CAD, MI, hypertension, congestive heart failure, hyperlipidemia or COPD was predictive of a positive nuclear scan. Conclusion: clinically significant perfusion defects are found in a small but significant percentage of patients referred with an isolated complaint of dyspnea. Scan Results and Risk Category Patients Normal (SSS <4) 78% Low risk (SSS 4–8) 12% Intermediate risk (SSS 9–13) 6% High risk (SSS >13) 4%

Prenatal diagnosis for chromosome abnormalities: past, present and future

Prenatal diagnosis for chromosome abnormalities has been available for over 30 years. The most common referral indication is a raised risk of Down’s syndrome, and diagnosis has, until recently, been carried out by culture of cells from invasive prenatal sampling, followed by full karyotype analysis, with a waiting time of around 2 weeks for results. More recent developments in fluorescence in situ hybridisation (FISH) and quantitative fluorescence-PCR techniques have led to rapid 1-2 d reporting for Down’s syndrome, opening the way to the possibility of targeted testing based on referral indication, thus reducing the incidence of difficult counselling issues and potentially unnecessary pregnancy terminations following the unexpected discovery of anomalies such as balanced chromosome rearrangements. The future of prenatal diagnosis must lie in the non-invasive diagnosis of Down’s syndrome using fetal cells from maternal circulation.

Pattern of Referrals from a General Hospital to a Regional Tertiary Health Institution: Samtah Experience

Pattern of Referrals from a General Hospital to a Regional Tertiary Health Institution: Samtah Experience

Older adults. An 11-year longitudinal study of adult protective service use.

Little is known about the epidemiology of adult protective services agency (APS) utilization, the state entities charged with assessment and advocacy for disenfranchised older adults. To determine the prevalence of utilization by older adults and risk factors for APS. A longitudinal study using the New Haven Established Population for Epidemiologic Studies in the Elderly population, a cohort of 2812 community-dwelling adults who were older than 65 years in 1982. The main outcome measure was referral to the state ombudsman on aging for protective services. Over the 11-year follow-up period, 209 cohort members (7.4%) were referred to the ombudsman 302 times as protective service cases for a community prevalence of 6.4% after adjusting for the sampling strategy of the cohort. Self-neglect was the most common indication for referral (73% of the cases). While in bivariate analyses a variety of baseline sociodemographic features, functional impairments, medical conditions, and social network factors were associated with APS use, in multivariable analysis only sociodemographic variables remained independent risk factors including low income (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8 to 3.9), nonwhite race (OR, 2.2; 95% CI, 1.3 to 3.7), and age older than 75 years at cohort inception (OR, 1.9; 95% CI, 1.1 to 3.0). Prevalence of APS use by older adults is substantial, and sociodemographic features were the most compelling risk factors in our cohort. As the population ages, the number of older adults at risk for abuse, neglect, self-neglect, exploitation, and abandonment will increase; physicians will need to become familiar with APS referral pathways and mandatory reporting laws in their states.

Diagnosis and management of fetal cardiac tumors: a multicenter experience and review of published reports

Objectives. We sought to determine the prevalence and natural history of cardiac tumors in patients referred for fetal echocardiography.Background. Cardiac tumors are rare; the prevalence, reported from autopsy studies of patients of all ages, varies from 0.0017% to 0.28%. Despite many case reports, the prevalence and natural history of fetal cardiac tumors are unclear.Methods. Fourteen thousand fetal echocardiograms recorded over an 8-year period in seven centers were available for retrospective review. Medical records and echocardiograms were studied to determine the reason for referral, family history of tuberous sclerosis, prenatal and postnatal course and tumor description and type.Results. Cardiac tumors were present in 19 pregnancies (0.14%). Gestational age at diagnosis ranged from 21 to 38 weeks. The most common indication for referral was a mass on an obstetric ultrasound study. The tumors were singular in 10 patients and multiple in 9. Tumor size ranged from 0.4 × 0.4 to 3.5 × 4 cm, and the majority of tumors were not hemodynamically significant. There were 17 patients with rhabdomyomas, 1 with a fibroma and 1 with an atrial hemangioma. Tuberous sclerosis complex was diagnosed in 10 patients. Partial or complete tumor regression was seen in eight patients; tumors were unchanged in five; and three required operation.Conclusions. Fetal cardiac tumors, a rare condition, are often benign. The majority of tumors are rhabdomyomas, but not all fetuses with rhabdomyoma have tuberous sclerosis.

State-of-the-art flexible hysteroscopy for office gynecologic evaluation

To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost. A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage. Office-based hysteroscopy suite in the outpatient building of a tertiary institution. Women referred to this institution for gynecologic evaluation between February 1992 and December 1993. Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block. A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475. Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.

Percutaneous endoscopic gastrostomy — results of an irish single unit series

The technique of percutaneous endoscopic gastrostomy (PEG) was first described in 1980, as an alternative to traditional surgical methods. The main indication for PEG is the need for longterm nutritional support. It is reported to have many advantages over surgical gastrostomy, being safer and cheaper. We reviewed our experience with the first 44 patients referred to our unit for PEG. The most common indications for referral were stroke, head injury and post brain surgery. There was a success rate of 97.6% and a complication rate of 13.8%. One patient (2.3%) suffered major complications as a result of early tube displacement. There were no procedure related deaths in our series and no deaths as a result of an underlying disease process within 30 days, reflecting appropriate patient selection. All patients benefited nutritionally from PEG placement. Two patients recovered sufficiently to no longer require a gastrostomy and the tube was easily removed in both cases.

Fetal Echocardiography: Indications for Referral, Prenatal Diagnoses, and Outcomes

Three hundred three fetuses were studied with fetal echocardiography and 21 were diagnosed with congenital heart disease (CHD). Indications for study, prenatal findings, and postnatal outcomes were examined in all fetuses studied. The most common indications for referral were previous family history and fetal dysrhythmia. Of 189 fetuses studied for these indications, six had CHD. Indications with the highest proportion of abnormal studies included an abnormal four-chamber view of the heart (50% abnormal), fetal hydrops (30.8% abnormal), and polyhydramnios (25% abnormal). Five of 21 with CHD had chromosomal defects and eight had extracardiac anomalies. Two of the 21 fetuses with CHD survived. Present referral indications led to the diagnosis of the most severe lesions, yet reassurance is provided to many couples with normal fetuses. Fetal echocardiography is important in the care of the fetus at risk for CHD.

Small Bowel Barium Examination in Children

The indications for small bowel barium examination, the radiologic findings, and the clinical outcome were compared retrospectively in 331 children, aged 0 to 15 years. Sixty examinations (18%) were pathologic, which is in accordance with adult materials. The most common indications for referral were inflammatory bowel disease (48%) and small bowel obstruction (25%). The examinations were positive in 19 per cent and 17 per cent, respectively. Indications for referring patients with non-specific symptoms led to a low frequency of pathologic findings. A therapeutic or diagnostic procedure was performed in 38 of the 60 pathologic radiologic examinations (63%). In 18 patients (30%) a pathologic finding caused no change in therapy. No consistent difference in sensitivity, specificity or predictive values of a positive or negative result was found concerning enteroclysis or elective follow-through examination. For screening purposes of the small bowel in children follow-through examinations give adequate radiologic information and should be used instead of enteroclysis.

Small Bowel Barium Examination in Children

The indications for small bowel barium examination, the radiologic findings, and the clinical outcome were compared retrospectively in 331 children, aged 0 to 15 years. Sixty examinations (18%) were pathologic, which is in accordance with adult materials. The most common indications for referral were inflammatory bowel disease (48%) and small bowel obstruction (25%). The examinations were positive in 19 per cent and 17 per cent, respectively. Indications for referring patients with non-specific symptoms led to a low frequency of pathologic findings. A therapeutic or diagnostic procedure was performed in 38 of the 60 pathologic radiologic examinations (63%). In 18 patients (30%) a pathologic finding caused no change in therapy. No consistent difference in sensitivity, specificity or predictive values of a positive or negative result was found concerning enteroclysis or elective follow-through examination. For screening purposes of the small bowel in children follow-through examinations give adequate radiol...

Genetic counseling and genetic services in obstetrics and gynecology: Implications for educational goals and clinical practice

Analysis of genetic counseling and antenatal diagnostic services offered by a genetics unit in a women's hospital was undertaken to identify genetic needs of the obstetrician-gynecologist. For similar reasons we tabulated findings derived from a genetic questionnaire administered routinely to obstetric registrants. Certain well-defined indications for genetic referral were identified, allowing specific educational objectives to be formulated. Potential chromosomal abnormalities constitute the most common indications for referral, particularly advanced maternal age and repetitive abortions. A wide range of mendelian and polygenic/multifactorial disorders was encountered, albeit many individually rare. This suggests that the obstetrician-gynecologist should become familiar with principles of these modes of inheritance. However, educational objectives need not stress specific details of rare disorders but rather should emphasize the relatively few disorders that the obstetrician-gynecologist is likely to encounter. Realistic suggestions are offered to achieve these objectives.