Early Specialist Referral Research Articles

Benchmarking Time-to-Treatment Initiation in Sarcoma Care Using Real-World-Time Data.

Benchmarking is a fundamental tool for enhancing quality within a patient-centered healthcare framework. This study presents an analysis of time-to-treatment initiation (TTI) for sarcoma patients, utilizing a database encompassing 266 cases from the Swiss Sarcoma Network. Our findings indicate a median TTI of 30 days across the cohort, with bone sarcomas and deep soft tissue sarcomas demonstrating a shorter median TTI of 28 days, followed by superficial soft tissue sarcomas at 42 days. The data reveal that the use of real-world-time data (RWTD) may account for a longer TTI observed, as it offers more comprehensive capture of patient journeys, unlike conventional datasets. Notably, variability in TTI was observed between different treatment institutions, which underscores the need for standardized processes across centers. We advocate for a selective referral system to specialized centers to prevent capacity overload and ensure timely treatment initiation. Our analysis also identified significant delays in TTI for unplanned 'whoops'-resections, highlighting the importance of early specialist referral in optimizing treatment timelines. This study emphasizes the potential benefits of a streamlined, data-informed approach to sarcoma care. However, further research is required to establish the direct impact of integrated care models on TTI and patient outcomes in the context of sarcoma treatment.

Contemporary updates on ventricular arrhythmias: from mechanisms to management.

Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life-threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because ofthe heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline-directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well-established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first-line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow-up.

27516 Moving the needle with virtual education: Impact of chronic idiopathic urticarial education on patients and health care providers

Introduction: Updated guidelines point to early specialist referral and evidence-based management options for Chronic Idiopathic Uriticaria (CIU) that allow for quick symptom control. However, CIU patients/caregivers (P-C) continue to suffer due to delayed appropriate care initiation. Therefore, we collaborated with Asthma and Allergy Foundation of America (AAFA) to create separate but aligned online patient and health care provider (HCP) education to help close treatment and communication gaps. Programs were launched in April/May 2020, and remain on-demand for one year.

Ocular Manifestations in Colombian Patients with Systemic Rheumatologic Diseases.

PurposeTo establish the prevalence of ocular involvement in a Colombian population with rheumatologic diseases.DesignObservational cross-sectional study.MethodsWe included a probabilistic sample size of 797 patients who attended a rheumatologic disease center in Bogotá, Colombia. Statistical analysis with descriptive measures and Chi-square independence test between rheumatologic diseases and ophthalmological symptoms and diseases was performed.ResultsEighty-four percent of the population were women, and the mean age was 54.61± 15.64 years. The most common condition was rheumatoid arthritis (33.37%), followed by fibromyalgia (22.71%), Sjögren Syndrome (19.72%), and systemic lupus erythematosus (9.91%). Almost 7% of the patients presented polyautoimmunity. Thirty-five percent of the patients reported one or more ophthalmological symptoms, being dry eye sensation the most common (30.86%), followed by ocular pain (2.76%), red-eye, and decreased visual acuity (both 2.63%). Similarly, 21.45% of the patients presented one or more ophthalmological diagnoses, being keratoconjunctivitis sicca the most common (15.93%), followed by cataract, uveitis (1.38% each), and scleritis (1.25%).ConclusionAlmost a third of the patients reported any ocular involvement. It is crucial to be aware of the most common ophthalmic manifestations among the different rheumatologic diseases in our population, to offer early specialist referral and timely treatment.

458 Hidradenitis suppurativa: Delays in care and misdiagnoses

Diagnostic delay and health care barriers are commonly faced by hidradenitis suppurativa (HS) patients. We sought to (1) identify reasons HS patients delay seeking care after symptom onset, and (2) identify common HS misdiagnoses by physicians. Between 2017 and 2019, 873 individuals with HS responded to an anonymous survey offered at several HS specialty clinics in the U.S. and online via Facebook HS support groups. Data regarding demographics, personal reasons for delay in presenting to a health care provider, and previously received misdiagnoses were collected. A majority of respondents (85%) reported a delay in seeking care, with a mean delay of 5.1 (STD 7.3) years. The top reason for delay was the belief that lesions would resolve (59.7%), while other reasons included embarrassment (42.4%) or lack of knowledge that treatments are available (32.3%). Younger HS patients were significantly more likely to report embarrassment (p<0.0001) and not knowing where to seek care (p<0.05). Individuals who reported at least one prior misdiagnosis of HS symptoms (66% of total survey respondents) had a mean delay in HS diagnosis of 10.4 years. The most common misdiagnoses were abscesses (45.4%), cysts (43.7%), and acne (31.2%). Compared to Hurley Stage 1 and 2, Hurley Stage 3 respondents were significantly more likely to have been misdiagnosed with MRSA (p=0.0021), abscesses (p<0.0001), and sexually transmitted infections (p<0.0001). HS patients have significant delays in care and are frequently misdiagnosed when they first present to a healthcare provider. Reasons for barriers to care are multifactorial but all contribute to increased disease burden. Outreach to younger individuals and public awareness programs aimed at normalizing this disorder, along with improved front-line provider education supporting early specialist referral may be especially valuable.

Axial spondyloarthritis 10 years on: still looking for the lost tribe.

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

Therapeutic challenges and clinical characteristics of single-sided deafness in children

IntroductionThe clinical implications of single-sided deafness (SSD) in children has historically been underappreciated by patients and providers alike, despite a large body of literature on the wide-ranging neurocognitive, language, scholastic, and functional impairments that occur. Conventional amplification options are marked by variable results and frequent loss of follow-up. MethodsRetrospective case series for pediatric SSD from 2008 to 2018. Results88 children with congenital SSD were identified. Seventeen (N = 17/88, 23.9%) passed their newborn hearing screen. Median age at first otolaryngology evaluation was 0.65 years (range 0.1–16.9 years). Most common etiologies included cochlear nerve deficiency (N = 39, CND, 44.3%), unknown (N = 30, 35.2%), inner ear malformation (N = 7, 8.0%), and congenital cytomegalovirus (N = 6, 6.8%). 32.5% of patients elected for continued observation only, followed by bone conduction hearing aid (27.7%), contralateral routing of sound aid (20.5%), conventional hearing aid (13.3%), or cochlear implant (6%). Lack of follow-up at ≥1 year was common (39.8%). Of those with device use data (N = 39), 84.7% reported either discontinued or <6 h of daily use. ConclusionsDespite early diagnosis and evaluation, the pediatric SSD cohort is characterized by high rates of loss of follow-up and amplification discontinuation. Cochlear nerve deficiency is commonly seen in congenital SSD. Early specialist referral is critical for habilitation evaluation. Patients and caregivers should be educated on the significant implications of unilateral hearing loss.

Case Series and Literature Review of Ophthalmologic Disorders Seen in a Specialist Rheumatology Clinic in Lagos, Nigeria

ABSTRACTPurpose: To highlight the pattern and treatment outcomes of ophthalmologic disorders referred to a private specialist rheumatology clinic.Methods: Retrospective review (January 2015–December 2016) of referrals from Eye Foundation Hospital, Lagos to Arthrimed Specialist Clinic, Lagos. Case records were retrieved and relevant information extracted. Ethical standards were observed.Results: Twenty-two referrals (35 eyes) were received out of 643 patients (3.4%) seen during the study period. The majority were female (63.6%) with mean age 48.9 ± 19.3 years and bilateral disease (59%). Diagnoses included uveitis (45.5%), optic neuritis (36.4%), non-specific autoimmune eye disease (9.1%), keratoconjunctivitis sicca (4.5%), and giant cell arteritis (4.5%). Treatment was with steroids and immunosuppressive agents. Fourteen patients improved (63.6%), five remained unchanged (22.7%), while three worsened (13.6%).Conclusions: Our patients were mostly fourth-decade females with bilateral disease. Uveitis was the commonest presentation, and two-thirds of the treated patients improved after treatment. Early specialist referral and co-management of severe autoimmune eye diseases are desirable.

Management Thyroid Disease in Pregnancy: Preconception, and the Postpartum Complications

Pregnancy has a profound impact on the thyroid gland and thyroid function since the thyroid may encounter changes to hormones and size during pregnancy. The diagnosis and treatment of thyroid disease during pregnancy and the postpartum is complex but knowledge regarding the interaction between the thyroids and pregnancy/the postpartum period is advancing at a rapid pace. For women known to have hypothyroidism, an increase in thyroxine dose by 20–40% when pregnancy is confirmed usually ensures they remain euthyroid. Treatment of subclinical hypothyroidism is recommended if the woman has antithyroid antibodies. Treatment of hyperthyroidism, unless it is related to human chorionic gonadotrophin, involves propylthiouracil in the first trimester. Carbimazole may be used in the second trimester. Thyroid function tests are checked every month and every two weeks following a change in dose. Women with a current or a past history of Graves’ disease who have thyrotropin receptor antibodies require early specialist referral as there is a 1–5% risk of fetal hyperthyroidism. Women with thyroid disorders in pregnancy should be followed up by their GP in the postpartum period. Postpartum thyroiditis may present months after delivery.

Thyroid disorders in pregnancy and postpartum.

Thyroid dysfunction in pregnancy has consequences for mother and baby. Potential problems include pre-eclampsia, prematurity and congenital abnormality. For women known to have hypothyroidism, an increase in thyroxine dose by 20–40% when pregnancy is confirmed usually ensures they remain euthyroid. Treatment of subclinical hypothyroidism is recommended if the woman has antithyroid antibodies. Treatment of hyperthyroidism, unless it is related to human chorionic gonadotrophin, involves propylthiouracil in the first trimester. Carbimazole may be used in the second trimester. Thyroid function tests are checked every month and every two weeks following a change in dose. Women with a current or a past history of Graves’ disease who have thyrotropin receptor antibodies require early specialist referral as there is a 1–5% risk of fetal hyperthyroidism. Women with thyroid disorders in pregnancy should be followed up by their GP in the postpartum period. Postpartum thyroiditis may present months after delivery.

Traction alopecia: A neglected entity in 2017.

Traction alopecia was first described in 1904 but is still a cause of scarring hair loss in young women worldwide. It is unique in being initially a reversible then an irreversible (scarring) form of alopecia. Linked to tightly-pulled hairstyles, it is seen across all races. The pattern of hair loss depends on the style creating it but most commonly affects the frontotemporal hairline. There are some new examination findings associated with traction alopecia, which are traction folliculitis, the fringe sign and hair casts (pseudonits) on dermatoscopy. These may prove key in prompting early specialist referral. The mainstay of current treatment is cessation of the contributing hairstyles. Camouflage, anti-inflammatory or growth-stimulating topical preparations are second line treatments. In later stages of severe traction alopecia hair transplantation may be the only effective treatment. The evidence basis for medical intervention with topical agents is anecdotal at best. Furthermore, additional research is required to clarify the pathogenesis of this biphasic alopecia. Until then, prompt diagnosis and identification of causative hairstyles are focus of current dermatological practice.

Diagnostic and Prognostic Biomarkers in the Rational Assessment of Mesothelioma (DIAPHRAGM) study: protocol of a prospective, multicentre, observational study

IntroductionMalignant pleural mesothelioma (MPM) is an asbestos-related cancer, which is difficult to diagnose. Thoracoscopy is frequently required but is not widely available. An accurate, non-invasive diagnostic biomarker would allow early...

Hiv-Exposed but Uninfected Infants: Identifying Developmental Delay and the challenges faced in Accessing Developmental Services from a Canadian Tertiary Centre

Abstract BACKGROUND: Children born to HIV-positive mothers but are HIV uninfected (HEU) are at increased risk for adverse developmental outcomes. The literature suggests that the increased risk is more related to social determinants of health rather than effects of perinatal exposures to HIV and antiretrovirals. Developmental screening and early referral do result in improved outcomes and so HEUs should benefit from anticipatory guidance and early specialist referral. OBJECTIVES: We aimed to identify the rate of development screening, identification and referral of developmental concern, and referral completion in a provincial family-centered HIV clinic caring for 20-30 HIV exposed newborns per year and secondarily identify barriers to referral completion. DESIGN/METHODS: We conducted a retrospective review of all of the HEU cared for at this outpatient clinic born between January 1, 2008 and June 30, 2013 to examine the frequency of developmental concerns, referral rates for children with documented concerns, and referral outcomes. RESULTS: We reviewed 112 subjects: 64 (57%) male; 87 (77%) born at term (&amp;gt;37 weeks). 78 (66%) of the families had one or more social vulnerabilities (parental ill health apart from HIV, poverty, limited literacy, limited English language skills, etc), including 43 (38%) who had some involvement with child protection services. 104 (92.8%) had at least one documented developmental assessment using standardized tools. Among these 104, 46 (44.2%) were noted to have a developmental concern and of those, 40 (87.0%) were referred to at least one developmental service provider or general pediatrician. There were a total of 43 referrals to developmental service providers; 58.1% occurred at time of study completion, and 60.0% for which recommendations were formally communicated. Of 36 referrals to general pediatricians, 69.4% had occurred, 92.0% of which recommendations communicated back to the clinic. Barriers to referral completion included inability to contact caregivers (7.3%), patient no-show (13.0%), waiting lists (23.2%), and other (56.5%). CONCLUSION: The large majority of patients were screened and referred when indicated, but a significant number of patients either were not assessed by the secondary provider, or no information was communicated back to the clinic. Multiple barriers at the clinic, patient, and referral centre level were identified. The discrepancy in referral completion between developmental service provider referrals and general pediatrician referrals, may further highlight the difficulty HEU families have navigating our provincial developmental services. Future work will examine how to overcome these barriers in a vulnerable population.

Blunt Abdominal Trauma Leading to Pancreatic Injury in Childhood. Delay in Diagnosis Leads to Poor Outcomes—A Case Presentation

This case report illustrates the difficulty in diagnosing paediatric patients with life threatening pancreatic injuries. A high index of suspicion is essential as late diagnosis significantly affects outcomes. A 9-year-old child presented with epigastric pain following an accident on his pushbike. The patient was examined in paediatric accident and emergency (A/E) and was discharged. He returned twice more to A/E and on the third visit, 5 days after the initial incident, a CT scan was performed. This showed a classical injury to the body of the pancreas with a collection in the lesser sac. The patient was transferred to the regional hepato-pancreato-biliary unit (HPB unit) and underwent surgery. Pancreatic injuries can be difficult to detect clinically and patients may be well on initial presentation with normal observations and routine bloods. Early CT scanning confirms the diagnosis and results in early specialist referral and better outcomes.

Effect of Early Referral to Specialist in Dementia on Institutionalization and Functional Decline: Findings from a Population-Based Study.

Although early diagnosis has been hypothesized to benefit both patients and caregivers, until now studies evaluating the effect of early dementia diagnosis are lacking. To investigate the influence of early specialist referral for dementia on the risk of institutionalization and functional decline in Activity of Daily Living (ADL). Incident dementia cases were screened in a prospective population-based cohort, the Three-City Study, and initial specialist consultation for cognitive complaint was assessed at dementia diagnosis. Proportional hazard regression and illness-death models were used to test the association between specialist referral and, respectively, institutionalization and functional decline. Only one third of the incident individuals with dementia had consulted a specialist for cognitive problems early (36%). After adjustment on potential confounders (including cognitive and functional decline) and competing risk of death, participants who had consulted a specialist early in the disease course presented a higher rate of being institutionalized than those who did not (Hazard Ratio = 2.00, 95% Confidence Interval (CI): 1.09- 3.64). But early specialist referral was not associated with further functional decline (HR = 1.09, 95% CI: 0.71- 1.67). Early specialist referral in dementia is associated with increased risk of institutionalization but not with functional decline in ADL. These findings suggest that early care referral in dementia may be a marker of concern for patients and/or caregivers; subsequent medical and social care could be suboptimal or inappropriate to allow patients to stay longer at home.

A report of a regional service for post-prostatectomy urinary incontinence: a model for best practice?

Post-prostatectomy incontinence (PPI) is a potentially highly significant complication of a common urological procedure. Pathophysiology may be multifactorial but most commonly involves urinary sphincter weakness. The gold standard treatment for severe incontinence is artificial urinary sphincter but multiple alternatives exist. The growing incidence of PPI has led to the development of a specialized regional service dedicated to management. In 2004 a regional referral protocol for PPI was established with a dedicated clinic at a single centre for assessment and management including videourodynamics, pelvic floor rehabilitation, biofeedback and a consultant with a specialist interest in PPI surgery. Data regarding all in-house and tertiary referrals to this clinic between 2004 and 2011 were analysed with patients categorized by symptom severity. A total of 267 patients were referred to the post-prostatectomy service (mean age 66.6, range 49-83 years) with numbers increasing year on year. Two-thirds of these were tertiary referrals: 27.7% of referrals were for mild symptoms, 35.2% moderate and 33.3% severe. One-third of referrals were made within 2 years of the primary procedure. Just over half of referred patients underwent invasive treatment including 24.3 artificial sphincter (24.3%) and male slings (22.8%). 7.5% patients were managed with medication, 14.6% were managed conservatively with containment therapy only. One-fifth remain under assessment or have deferred treatment. PPI is of increasing personal and societal impact which should be identified early and supported. Investigation and management can be standardized and intervention at a high volume centre achieved by early specialist referral.

Causes of Visual Loss Associated with Uveitis in a Singapore Tertiary Eye Center

Purpose: To identify the causes of visual loss associated with uveitis and its risk factors.Methods: Review of 359 patients attending a uveitis service.Results: Anterior uveitis (n = 229, 63.8%) was most common, followed by panuveitis (n = 55, 15.3%). There were 82 infective cases with 29.3% associated with tuberculosis. Visual loss occurred in 100 (27.9%) patients, of which 27 (7.5%) had severe visual loss. The main causes of visual loss were cataract (26%) and glaucoma (12%). Cystoid macular edema (14.8%) accounted for severe visual loss. Panuveitis was predictive for visual loss (p = 0.022, odds ratio (OR) 2.22) and severe visual loss (p = 0.01, OR 3.47). Posterior uveitis (p = 0.005, OR 5.01) and chronic uveitis (p = 0.008, OR 3.83) also showed higher risk for severe visual loss.Conclusion: With panuveitis being the second most common presentation, early specialist referral is essential in preventing visual loss.

Current trends in the management of septic arthritis: A national survey of orthopaedic surgeons and rheumatologists: Category: Scientific free paper

Joint infection or septic arthritis (SA) is a clinical emergency. Prompt treatment is required to avoid irreversible destruction of articular cartilage and systemic complications. Reported mortality figures are as high as 11% for monoarticular sepsis and 50% for polyarticular sepsis. Where SA is suspected, early specialist referral is essential. In the UK, the definitive care of patients with a septic joint is commonly carried out under the care of rheumatologists or orthopaedic surgeons (OS).

Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disease of the elderly and represents the commonest indication for long-term steroid therapy in the community. Important risk factors include being over 50 years of age and female. Patients experience disability in activities of daily living because of pain and stiffness. Many conditions can mimic PMR (perhaps better called ‘polymyalgic syndrome’) and hence both over and under-diagnoses are common. International efforts have recently been initiated to develop classification criteria and to consider a stepped diagnostic approach in the evaluation of PMR. Most patients require steroid therapy for about 18 to 24 months and hence there is a need for careful balancing of benefit versus risks. Methotrexate may be useful in patients with frequent relapses. Osteoporosis prophylaxis must be initiated early to prevent bone loss and reduce fracture risk. Lack of a rapid, complete and sustained response to low dose steroids or presence of atypical features should alert the clinician to initiate a prompt and early specialist referral.

Presentation and management of aural foreign bodies in two Australian emergency departments

To survey and compare the type and management of foreign bodies found in adult and paediatric ears presenting to an Australian otorhinolaryngology and a general ED. Retrospective case study with data collated from two centres. Chart reviews of a total of 330 patients presenting with aural foreign bodies to the ED of the Royal Victorian Eye and Ear Hospital and the ED of The Bendigo Hospital, both situated in the state of Victoria, Australia, were surveyed for patient demographics, foreign body description and referral and removal pattern. Two hundred and seventeen adults and 113 children were included in the study. The most common foreign bodies in children were beads, cotton tips, insects and paper, and in adults cotton tips, insects, cotton wool and silicone ear plugs. Flying insects were far more common in the Australian population than cockroaches found in surveys in other countries. Children were significantly more likely to have initially been seen by their Local Medical Officer than adults (P < 0.001) and to require a general anaesthetic for removal of the object(s) (P < 0.001). Adults were more likely to have associated otitis externa at the time of presentation (P < 0.05). Aural foreign bodies are a frequent presentation to the ED. Recognition of patients requiring early specialist referral is important. Adults present with a different profile of aural foreign objects to children and require different management. The use of cotton tips or cotton wool in the external ear canal and silicone ear plugs should be discouraged.