Multiple Referral Research Articles

Identifying and Preparing Patients for CAR-T Therapy A Roadmap for Relapse/Refractory Multiple Myeloma Referral

Identifying and Preparing Patients for CAR-T Therapy A Roadmap for Relapse/Refractory Multiple Myeloma Referral

Thrombolysis in Acute ST Elevation Myocardial Infarction: Determination of Door to Needle Time in a Tertiary Medical Centre

Door to needle (DTN) time for thrombolysis in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre (ED, UKMMC) is an indicator that can reduce mortality and morbidity of patients with ST Elevation Myocardial Infarction (STEMI). This study was conducted to determine factors that influence DTN time for acute ST Elevation Myocardial Infarction (STEMI) and whether it has achieved the recommended time of 30 minutes. A cross-sectional study was conducted among patients diagnosed with acute STEMI and thrombolysed in ED, UKMMC from June 2016 until March 2017. A data collection sheet was used to collect patient’s demographic data and clinical data which included time of arrival to ED, time of initial electrocardiogram (ECG), time of drug preparation and time of thrombolytic delivery to the patient. A total of 98 patients were included in this study. Majority of patients (77.6%) were thrombolysed more than 30 minutes following ED arrival. Mean DTN in ED, UKKMC was 59.28 + 36.01 minutes. The mean door to ECG time was 7.19 + 8.08 minutes and the mean drug preparation time was 9.86 + 7.51 minutes. Out of 76 (77.6%) patients that were thrombolysed after 30 minutes of ED arrival, 59.2% (n=45) were due to multiple disciplinary referral. Other factors were delay in performing initial ECG 19.8% (n=15), incorrect initial ECG interpretation 9.2% (n=7) and unavoidable need for prior resuscitation 9.2% (n=7). As a conclusion this study showed that there was an unacceptable delay in hospital thrombolysis for acute STEMI.

Patient and tumour factors influencing canine mast cell tumour histological grade and mitotic index.

The aim of this study was to identify patient and tumour factors most frequently associated with high histological grades of canine mast cell tumours (MCTs). Search criteria in a shared database of multiple Animal Referral Hospital locations within Australia generated 400 canine MCTs in 286 patients. Patient and tumour data were extrapolated and the association between a tumour being histologically high grade and patient and tumour factors, including: patient breed, patient gender and neuter status, patient age at MCT excision, tumour location and tumour size was assessed using univariate analysis. The study consisted of 90 (21.9%) tumours meeting histological high-grade criteria. Shar peis were the most likely breed to have high grade MCTs, whereas the Pug and the Golden Retriever were the least likely breeds to develop high-grade MCTs. No significant difference in risks could be established between the age at which the tumour was excised, or the gender and neuter status of patients. MCTs of the inguinal region were the most likely single location to be high grade. Tumour size did not influence the likelihood of a tumour being high grade or low grade. The results of this study suggest that patient and tumour factors may play a role in the histological grades of canine MCTs.

Risk Factors for Delayed Referral to a Craniofacial Specialist for Treatment of Craniosynostosis

To assess the impact of age at referral on treatment options in craniosynostosis and to identify risk factors for referral delays in this population. A retrospective cohort study was performed on patients with an abnormal head shape diagnosis treated at a single academic medical center between January 1, 2004 and January 1, 2014. Newly diagnosed patients with craniosynostosis were identified and referral patterns were examined. A multivariate logistic regression model was used to identify risk factors associated with the range of ages at initial referral. A total of 477 patients were evaluated at our institution, 197 of whom were subsequently diagnosed with craniosynostosis. The median age at initial appointment was 5.6 months (mean 8.2 months). Only 28% of children were referred within 3 months of birth. Patients referred within 3 months of birth were less likely to have had preappointment imaging than those patients referred slightly later (OR 2.53, CI 1.07-5.98, P = .035). Several variables were associated with referral after 12 months of age including multiple suture involvement (OR 4.21, CI 1.06-16.68, P = .041), minority race (OR 4.96, CI 1.91-12.9, P ≤ .0001), and referral by a nonpediatrician (OR 6.9, CI 1.73-27.49, P = .006). Obtaining imaging before referral to a specialist for abnormal head shape was associated with a delay in evaluation and potentially increases radiation exposure and limits treatment options in patients with craniosynostosis. In addition, children from minority groups, children referred from someone other than a pediatrician's office, and those with multiple suture craniosynostosis are at increased risk of delayed referral. Further studies into the cause of these delays are warranted.

It's in Our Hands: Multiple Referral with a Primary Committee

In 1995 the U.S. House of Representatives instituted a new rule that required the Speaker of the House to designate a primary committee on legislation referred to multiple committees, and in this paper we model the effect of instituting a “primary referral” rule on committee legislative activity. We find that competition among House committees under joint referral encouraged committees to over-invest in legislative hearings to try to win responsibility for shepherding bills through the legislative process. We further find that designating a committee of primary referral reduces such investment and has unintended consequences counter-acting the intended efficiency gains.

Complicated multiple pregnancy referral, treatment and outcomes at the NSW Fetal Therapy Centre.

Objectives: To determine the indications for referral, sonographic workload, diagnoses and outcomes of women with a multiple pregnancy referred to the New South Wales Fetal Therapy Centre (NSW FTC). Methods: Retrospective cohort study of twin and higher order multiple (HOM) pregnancies referred to the NSW FTC at the Royal Hospital for Women (RHW) Department of Maternal Fetal Medicine (MFM), Sydney from January 2007 to December 2009. Results: There were 176 twin pregnancies (138 monochorionic diamniotic, 29 dichorionic diamniotic and nine monoamniotic), and 26 HOMs referred (23 triplet and three quadruplet pregnancies). Indications for referral were: twin to twin transfusion syndrome (TTTS) 103 women, fetal anomaly 31 women, intrauterine growth restriction (IUGR) 12 women, serial surveillance of twins or HOM 37 women, and fetal reduction of HOM (nine women). In 80.2% the pathological referral diagnosis was confirmed. The average number of ultrasounds was five (range 1–24), with 90 women (45%) receiving invasive therapy. Thirty‐five percent (71) of referrals were from outside Sydney, including eight interstate and 11 overseas referrals. Two‐thirds of out of area referrals were able to return to their referral hospital for birth: 95 women (47%) delivered at RHW. Conclusion: TTTS was the most common reason for referral, with a high concordance between referral and initial diagnosis. RHW accepted a large number of out of area referrals, in keeping with its role as the NSW FTC. Twin and HOM pregnancy referrals represent a significant workload for the 5 department, with many women also requiring invasive therapy.

P.12.7 Swallowing evaluation in Escobar syndrome : A case report

Escobar syndrome is a rare disease characterized by multiple ptergia, skin webs and congenital anomalies like craniofacial defects, vertebral anomalies, cleft palate, kyphosis and scoliosis. Despite the passage of the disease is reported as an autosomal recessive, autosomal dominant and X-linked lethal multiple pterygium syndromes have also been reported in the literature. We aimed to discuss the swallowing physiology of a case who referred with swallowing disorders. Our case was 20 months old, male, 75 cm height and 10.5 kg weight and he fed by oral way. He was followed by 2.5 months with tracheostomy tube. He had pulmonary infection history once a month. Swallowing disorder was thought to be the cause of pulmonary infection so the swallowing evaluation was performed. Modified Barium Swallowing Evaluation was performed and the penetration aspiration scale (PAS) was used to define the aspiration severity. Delay in swallowing reflex (2–5 s) was determined. Silent aspiration was seen in liquid consistency with bottle feeding. The PAS score was 7. Oral intake with liquid thickener was recommended because swallowing evaluation showed that the cause of infections was liquid aspiration. Our results showed that swallowing disabilities should also be considered in this syndrome characterized by multiple congenital anomalies and necessary referral should be done in the early period.

OS017. Maternal death risk factor score based on hospital reference pattern and maternal condition of eclamptic woman in Soetomo Hospital, Surabaya, Indonesia

Maternal Mortality Rate in Indonesia is still high, around 230/100,000 live birth in 2005. Eclampsia is the second most cause of maternal death (about 13%). We have a very high prevalence of eclampsia in our center (Surabaya) about 1.08% of all delivery. One of our main problem about eclampsia case is multiple referral hospital system, because we do not have many tertiary center for this case. We assumed that high incidence of maternal death because of eclampsia is caused by this factor. To evaluate relationship between hospital referral system and maternal condition of eclamptic woman with maternal death event and develope scoring system to predict maternal death event on eclamptic woman. This is a case control study with retrospective observational analytic design, involve all eclamptic woman whom reffered and admitted to Soetomo hospital (Indonesia) from 1 January 2005 until 31 December 2009. Total eclamptic woman was 160 cases, with 12 maternal death on case group and 148 survive maternal on control group. Research variable includes maternal condition (ages, parity, eclampsia type, complication) and hospital referral pattern (ANC, Magnesium Sulfate, anti-hypertensive drugs, multiple hospital referral, health workers accompanion during patient referral). Primary outcome includes maternal death. There is significant association between multiple hospital referral (RO 6.1, P=0.083), maternal age >35 (RO 17.4, P=0.032), lung oedema (RO 19.1, P=0.065), renal failure (RO 98.8, P=0.002), intra cranial hemorrhage (RO 6319.7, P⩽0.0001), Eclampsia type (RO 0.009), on eclamptic women with maternal death. No significant association between parity (RO 0.3 P=0.310), HELLP syndrome (RO 2.2 P=0.478), Magnesium Sulfate given before patient reffered (RO 0.7, P=0.685), ANC quantity (RO 0.9 P=0.844), health workers accompanion during referral (RO 0.9, P=0.901), on eclamptic women with maternal death event. There are 6 significant variable includes Maternal complication (ICH, renal failure, lung oedema), Maternal ages >35 years, antihypertensive drugs, multiple hospital referral, multiparity, and eclampsia type that can be made a scoring system. We develop scoring system based on risk factor that can be used to predict maternal death event on eclamptic woman.

Multiple Referral and U.S. House Legislative Success in the 1990s

We examine the impact of multiple referral on legislative processing in the U.S. House of Representatives from 1991-98. Previous literature leaves off with the 1980s, but party control of the House changed in the 1990s and with it, came a new approach to multiple referral. Did this change alter the impact of multiple referral status on bill progression? In the main, our analysis confirms certain previous findings, while adding some interesting new twists. While multiple referral hurts a bill’s chances of success in some stages of statute-making (committee passage, floor passage), a finding consistent with the literature, we find that it provides a boost to chances of receiving committee attention in the first place. Moreover, we find that the hit that multiply referred bills take in committee and on the floor is much greater than suggested previously. Separate analyses conducted before and after the Republican reforms of 1995 reveal distinct differences. For example, in the Re-publican-controlled environment from 1995-1998, multiple referral bills were slightly more likely to see the House floor, whereas they were less likely to make it in the Democratic House from 1991-94.

A Process for Developing Community Consensus Regarding the Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder

A Process for Developing Community Consensus Regarding the Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder

Characterization of wheezing phenotypes in the first 10 years of life.

Childhood wheezing illnesses are characterized into different phenotypes. However, severity of the disease associated with these phenotypes has not been extensively studied. To determine characteristics of childhood wheezing phenotypes in the first decade of life using health outcomes plus measurements of atopy, lung function and bronchial hyper-responsiveness. A whole population birth cohort (n = 1456) was prospectively studied to examine the natural history of childhood wheezing. Children were seen at 1, 2, 4 and 10 years for questionnaire completion and prospectively collected data used to define wheezing phenotypes. Assessment was made of adverse health outcomes plus spirometry, bronchial hyper-responsiveness, serum IgE measurement at 10 years and skin test sensitization at both 4 and 10 years for wheezing phenotypes. Phenotypic analysis identified that 37% early life wheezers (symptom onset by age 4 years) still wheezed at 10 years. These persistent wheezers showed significantly more physician-diagnosed asthma in early life (P < 0.005 at 2 years) than early transient wheezers (wheezing transiently with onset by age 4 years). Overall they experienced greater multiple hospital admissions (P = 0.024), specialist referral (P = 0.009) and use of inhaled (P < 0.001) and oral steroids (P < 0.001) than early transient wheezers. They also demonstrated enhanced bronchial hyper-responsiveness compared with early transient wheezers (P < 0.001). However, both groups of early life wheezers showed impairment of baseline lung function at 10 years in comparison with non-wheezers: FEV1 (P < 0.029) and FEV1/FVC ratio (P < 0.001) with persistent wheeze and PEF (P = 0.036) with early transient wheeze. Late-onset wheezers (onset from 5 years onwards) had similar BHR to persistent wheezers but maintained normal lung function at age 10 and had lower cumulative prevalence of adverse health outcomes than persistent wheezers. Persistent wheezing with early childhood onset is associated with substantial morbidity in the first decade of life in association with high levels of atopy, bronchial hyper-responsiveness and impaired lung function at 10 years of age. Late-onset wheezing in the first decade of life could harbour potential for similarly significant disease subsequently.

Minimizing the Risks of Delegation: Multiple Referral in the German Bundesrat

preference outliers. This article establishes that committee assign? ment procedures in the German up? per house, the Bundesrat yield com? mittees that do not always reflect the chamber's partisan preferences. This non-American setting provides lever? age on a central question in legisla? tive studies: how can a chamber ensure responsive lawmaking when delegating to unrepresentative com? mittees? I argue that Bundesrat pro? cedures, including multiple referral, equal reporting rights, and a selfselection referral process, minimize the risks of delegation. A spatial model illustrates how the Bundesrat

Strategic responses to institutional change: Parties, committees and multiple referral

Although multiple referral seems to remove committees' gatekeeping power, strategic opportunities exist for motivated committees to dominate late stages of the legislative process. Multiple referral does not necessarily diminish the power of committees, but it does solve an important problem for the leadership. If the goal of the leadership is to maximize the number of majority party members reelected, it will make procedural decisions to favor groups within the majority party that care the most about the issue. Multiple referral provides the leadership with information about preference intensity when jurisdiction is unclear. The committee willing to exert the most effort for a bill, even if this effort takes the form of strategic behavior, is the committee most affected by the issue.

Committee Gatekeeping and Proposal Power under Single and Multiple Referral

A common feature of the legislative process in several American legislatures - especially the US House - is the referral of legislation to multiple committees. Multiple referral calls into question traditional interpretations of committee power and thus warrants careful theoretical analysis. This paper uses a basic spatial model to analyze the impact that multiple referral has on committee proposal and gatekeeping power. After discussing several implications yielded by the model, the paper tests - and finds support for - the hypothesis that multiple referral increases obstruction.

Interested Experts and Policy Advice: Multiple Referrals under Open Rule

This paper examines a simple model of multiple referrals under open rule. In the model, an uninformed House multiply refers legislation to two specialist committees (experts) who have policy preferences. Under open rule, committees′ proposals are analytically equivalent to speeches giving advice to the House about what policy to choose. Two different forums for giving advice, or making proposals, are examined: multiple joint referral and multiple sequential referral. The informational properties of these forums are compared to each other and to single referral.

Multiple Referral of Legislation in the U. S. Senate

A small but significant portion of bills and resolutions in the U.S. Senate are handled not by the single committee but by two or more committees. The practice is of longer standing in the Senate than in the House of Representatives, which instituted multiple referrals only in 1975. Yet since the Senate's multiple-referral rules were broadened in 1977, the proportion of multiply-referred bills has not soared, as it has in the House. Nor have Senate leaders used the device extensively (as House leaders have) as a way of orchestrating and scheduling committee processing of high-priority measures. This paper describes the Senate's use of multiple referrals, using figures on overall frequency of use, committee variations, and typical committee pairs in handling multiply-referred bills. We examine the politics of intercommittee deliberations from the vantage point of the committees and the leadership. Finally, we speculate on the reasons for the two chambers' contrasting experience with multiple referrals.

One Bill, Many Committees: Multiple Referrals in the U. S. House of Representatives

Since the procedure of multiple referral was instituted in 1975, legislation in the House of Representatives is increasingly processed by two or more committees, not just a single committee. During 1985-1986, nearly a quarter of House committees' workload consisted of bills or resolutions shared with one or more other panels. This study analyzes statistically the more than 7,000 measures multireferred from 1975 to 1986, determining committee referral rates, referral patterns, success rates of legislation, and political strategies associated with multiple referral procedures. The objectives are to determine how the House and its committees are affected by the practice and to illuminate a previously ignored phenomenon: intercommittee politics.

The contribution of multiple pregnancy to perinatal mortality in Benin City.

The contribution of multiple pregnancy to overall perinatal mortality in the 3 major hospitals in Benin City has been reviewed. Although the incidence is 2.6% of all deliveries, it accounts for 14.3% of the overall perinatal mortality. The factors of importance in relation to perinatal loss included preterm delivery, low birthweight, birth order, malpresentation, mode of delivery, and failure to diagnose multiple pregnancy before labor. Bedrest is advocated. Health education is important in encouraging parturients to avail themselves of available antenatal facilities. A high index of suspicion for multiple pregnancy and referral of such patients to major units equipped to manage such high risk pregnancies will reduce fetal wastage.