National Referral Center Research Articles

Taurolidine-related adverse events in patients on home parenteral nutrition frequently indicate catheter-related problems

A catheter-related bloodstream infection (CRBSI) is a serious complication of home parenteral nutrition (HPN) treatment. Despite taurolidine's frequent use as catheter lock solution (CLS) to prevent CRBSIs and its presumed favourable safety profile, data on taurolidine-related adverse events (AEs) and the clinical implications thereof remain merely anecdotal. Aim of this study was to explore taurolidine-related AEs in our large cohort of HPN patients and to develop an algorithm on how to deal with these AEs in clinical practice. This retrospective cohort study comprised all adult HPN patients who used taurolidine as a CLS between 2006 and 2021at our national HPN referral centre. Primary outcome was to identify taurolidine-related AEs. Secondary outcomes were median time to a taurolidine-related AEs and development of a clinical algorithm. A taurolidine-related AE was defined as an event that occurred directly after instillation of taurolidine in the CVAD or at start of fluid/PN infusion. In total, 470 patients used taurolidine during 700.232 catheter days. In 89 (19%) patients, 103 mild- to severe AEs related to taurolidine were observed. Six patients developed an allergic reaction. Reported AEs compromised vascular access device-related problems (group A) or taurolidine-related problems (group B) in 53 (51%) and 50 (49%), patients, respectively. In groups A and B, 51 (85%) and 21 (18%) patients presented with taurolidine infusion-related pain. Upon rechallenge, 45 (85%) and 16 (32%) patients, respectively, successfully resumed taurolidine locking without residual symptoms. In this study, use of taurolidine as CLS was generally safe. Most reported AEs were vascular access device-related, and the majority of symptoms concerned pain. Upon rechallenge, a substantial number of patients, especially those in whom pain was the main symptom, could resume CLS locking after addressing the underlying catheter-related problem. Based on these results, we present a clinical algorithm for patients with possible taurolidine-related symptoms.

Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants.

Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR)=1.01; confidence interval (CI)=1.00-1.03, P=0.036] and the use of antiplatelet agents (HR=13.47; CI=1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30±27months. Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%).

Prognostic Factors in Advanced Adrenocortical Carcinoma: Summary of a National Referral Center's 20 years of Experience.

ContextAdrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis for both locally advanced and metastatic disease. Standard treatment with combination etoposide–doxorubicin–cisplatin–mitotane (EDP-M) is highly toxic and some patients benefit from mitotane monotherapy. However, identification of these patients remains challenging.ObjectiveWe present a summary of the Israeli national referral center’s 20 years of experience in treating advanced ACC, with the aim of identifying prognostic factors and assisting in treatment decision making.MethodsWe conducted a retrospective multivariate analysis of patients treated for metastatic or locally advanced ACC at Hadassah Medical Center between 2000 and 2020 to determine clinical, pathological, and treatment factors correlated with overall survival (OS).ResultsIn our cohort of 37 patients, a combination of modified European Network for the study of Adrenal Tumors (mENSAT) staging with either grade and R status, or age and symptoms was validated to stratify prognosis (P = .01 and P = .03, respectively). Patients who underwent R0 resection followed by radiotherapy or metastasectomy for oligometastatic disease had longer OS than patients with residual disease: median OS of 55 months vs 14 months, respectively, hazard ratio 3.1 (CI 1.4-6.7, P = .005). Patients treated with mitotane monotherapy had a significantly better prognosis, yet this result was attenuated in a multivariate analysis controlling for mENSAT and R status. Of patients treated with EDP-M, 41.4% experienced grade 3 or higher adverse events.ConclusionPatients with advanced ACC achieving R0 status have a better prognosis and might benefit from mitotane monotherapy.

Population structure of Mycobacterium tuberculosis from referral clinics in Western Siberia, Russia: Before and during the Covid-19 pandemic.

The dramatic change in global health imposed by the Covid-19 pandemic has also impacted TB control. The TB incidence decreased dramatically not because of the improved situation but due to undertesting, reduced resources, and ultimately, substantially reduced detection rate. We hypothesized that multiple and partly counteracting factors could influence changes in the local Mycobacterium tuberculosis population. To test this hypothesis, we analyzed M. tuberculosis isolates collected in Western Siberia, Russia, before and during the Covid-19 pandemic. A total of 269 M. tuberculosis isolates from patients admitted at referral clinics were studied. The pre-pandemic and pandemic collections included 179 and 90 isolates, respectively. Based on genotyping, both pre-pandemic and pandemic samples are heavily dominated by the Beijing genotype isolates (95% and 88%) that were mostly MDR (80 and 68%). The high proportion of MDR isolates is due to the specific features of the studied collections biased towards patients with severe TB admitted at the National referral center in Novosibirsk. While no dramatic change was observed in the M. tuberculosis population structure in the survey area in Western Siberia during the Covid-19 pandemic in 2020–2021 compared to the pre-pandemic collection, still we note a certain decrease of the Beijing genotype and an increase in the proportion and diversity of the non-Beijing isolates. However, the transmissible and MDR Beijing B0/W148 did not increase its prevalence rate during the pandemic. More generally, the high prevalence rate of the Beijing genotype and its strong association with MDR both before and during the pandemic are alarming features of this region in Western Siberia, Russia.

The relationship of human papillomavirus positivity with tumor characteristics in an Irish penile cancer population.

Penile cancer is a rare malignancy, with a European-wide annual incidence rate of 1/100 000 males. Approximately one-third of cases are attributable to human papillomavirus (HPV) infection. p16INK4a is a recognized surrogate marker for HPV infection in penile cancer. University Hospital Waterford (UHW) is the national referral center for penile cancer in Ireland. We report the prevalence of HPV infection and histological characteristics of an Irish penile cancer cohort using p16INK4a as a surrogate marker. Patients who attended UHW for penile cancer surgery between June 2015 and November 2020 were entered into a prospectively maintained database. Clinical, histopathological, and outcome data were collected. Over the study period, 70 patients with a histological diagnosis of penile squamous cell carcinoma had staining for p16INK4a, of whom 64% were positive. p16INK4a-positive patients were significantly younger at diagnosis, with a mean age of 61±15 years compared to 68±12 (p <0.05). Of note, 97% of tumors with high-risk histology were p16INK4a-positive (p<0.001). p16INK4a positivity was more prevalent among higher-grade tumors (p<0.02). Interestingly, p16INK4a status was not associated with recurrence-free or overall survival. Our data is representative of the Irish landscape in penile cancer over the last five years. Using p16INK4a staining, we demonstrate a high rate of HPV prevalence in penile cancer cases in our patient cohort, which is associated with prognostically worse tumor subtypes. This would suggest that HPV vaccination of adolescent boys is a useful public health intervention in preventing penile cancer in the Irish male population.

Incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years.

Postoperative pain in pediatric patients is one of most inadequately treated conditions. This study aimed to investigate the incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years at Siriraj Hospital-Thailand's largest national tertiary referral center. This retrospective study included pediatric patients aged 0-8 years who underwent surgery with epidural catheter during January 2015 to January 2020. Patients with missing data were excluded. Records from both the ward staff and the acute pain service were reviewed. All relevant data were extracted until the epidural catheters were removed. One hundred and fifty pediatric patients were included. The median age was 29 months and the range varied from 12 days to 98 months on the day of surgery, and 86 (57.3%) were male. The incidence of inadequate epidural analgesia was 32%. Most patients (95.8%) had an unacceptably high pain score within 4 hours after arriving at the ward. Univariate analysis revealed direct epidural placement, the length in epidural space less than 5 cm, and postoperative leakage to be substantially higher in the inadequate pain epidural analgesia group. When those factors were included in multivariate analysis, only length in epidural space less than 5 cm was identified as an independent risk factor. The incidence of inadequate epidural analgesia in this pediatric study was 32%. Multivariate analysis showed length of catheter in epidural space less than 5 cm to be the only factor independently associated with inadequate epidural analgesia.

Outcomes In Elective Induction Of Labour With μg Intravaginal Misoprostol In Postdate Singleton Live Pregnancy At Korle-Bu Teaching Hospital

Background: Induction of labour is indicated when the risk associated with expectant management of labour is higher. The most common indication for labour induction is postdate pregnancy and induction for this indication has been shown to reduce perinatal death. Misoprostol is the most commonly used drug for labour induction at the Korle-Bu Teaching, the leading national referral centre in Ghana. Method: To assess the outcomes in Elective Induction of Labour using 50 μg of intravaginal misoprostol in postdate singleton live pregnancies at Korle-Bu Teaching Hospital. This was a prospective cohort study carried out to measure the rates of vaginal deliveries and factors affecting vaginal deliveries during labour induction. One hundred and sixteen pregnant women of at least 41 weeks gestation. Women were included and followed up from the first insertion of misoprostol to delivery.Results: Eighty-six patients (74.1%) had vaginal delivery and 30 (25.9%) were delivered by caesarean section. Among those who delivered vaginally, 77 (89.5%) delivered within 24 hours. There was a significant association between mode of delivery and Bishop Score (P=0.002). The highest Apgar score at the first minute was 7 in 55 babies (47.4%) and the lowest was 3 in 2 babies (1.7%).Conclusions: The high rate of vaginal delivery and absence of induction related perinatal mortality confirmed the effectiveness and safety of misoprostol in postdate singleton live pregnancy at Korle-Bu Teaching Hospital.

Iatrogenic injury of the urinary tract during salvage procedures for pelvic sepsis: Experience of a national referral centre.

This study aimed to determine the incidence, consequences and outcomes of iatrogenic urinary tract injury (IUI) during salvage surgery for pelvic sepsis. Patients who underwent salvage surgery for pelvic sepsis after prior low anterior resection or Hartmann's procedure for rectal cancer were prospectively maintained in a database between 2010 and 2020 and reviewed retrospectively. The primary endpoint was the incidence of IUI. Secondary endpoints were timing of diagnosis (intra- vs. postoperative), reinterventions related to the IUI and healing of IUI. In total 126 consecutive patients were included, and IUI occurred in 13 patients (10%). A ureteric injury occurred in eight patients, bladder injury in four patients and a urethral injury in one patient. All patients with an IUI had radiotherapy as neoadjuvant treatment. The IUI was diagnosed postoperatively in 63% (n= 8/13) with a median duration between surgery and diagnosis of the IUI of 10 days (IQR: 6-15). The median number of reinterventions was five (range 1-31) in the group with a postoperative diagnosis and one (range 0-1) in the group with an intraoperative diagnosis. Four patients required a surgical reintervention, all concerning injuries diagnosed postoperatively. At the end of follow-up, 85% of patients (n= 11/13) had a healed IUI. Iatrogenic urinary tract injury is not uncommon in salvage procedures for pelvic sepsis, even in an experienced tertiary referral centre. Most injuries were diagnosed postoperatively which affects the severity of these complications, emphasising the need to improve intraoperative diagnostic modalities.

Non-continent Urinary Diversion (Ileal Conduit) as Salvage Therapy in Patients With Refractory Lower Urinary Tract Dysfunctions due to Multiple Sclerosis: Results of a National Cohort From the French Association of Urology (AFU) Neurourology Committee and the French-speaking Neurourology Study Group (GENULF)

To describe the outcomes of ileal conduit as a salvage therapy for refractory lower urinary tract dysfunctions (LUTDs) due to multiple sclerosis (MS) in a national neurourology referral center network. A retrospective multicenter French study was carried out to identify MS patients who underwent non-continent urinary diversion for refractory LUTDs from January 2010 to December 2015. Multiple sclerosis status, urological history, surgical indication and technique, postoperative complications, renal anatomy and function at last follow-up as well as number of rehospitalizations for urinary tract infections (UTI) were collected. Preoperative and postoperative urinary-related quality of life (urQoL) through the Qualiveen short-form questionnaire (QSF) and patient global impression of improvement (PGI-I) were collected and analyzed. Overall, 10 centers identified 211 patients with a mean age of 54±11 and mean preoperative EDSS (expanded disability status scale) score of 7.3±0.9. The main indication for diversion was MS progression leading to impossible intermittent self-catheterization (55%). Cystectomy was performed either by open (34.6%), laparoscopic (39.3%) or robotic (21.8%) approach (unknown: 4.2%) with cystectomy in all cases. Early complications were reported in 42% of the patients, mainly Clavien I or II grades. There was no difference in GFR (glomerular filtration rate) after surgery. After diversion, patients had fewer hospitalizations for UTI and better urQoL on QSF confirmed by evaluation of PGI-I. This study, reporting the largest series of ileal conduit in selected MS patients with end-stage LUTDs, showed significant improvement in symptomatic UTI and quality of life with a low high-grade complication rate.

Trajectory Pattern of Cognitive Decline in Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy.

Background and ObjectivesThe course and pattern of cognitive decline in ischemic cerebral small vessel disease remain poorly characterized. We analyzed the trajectory pattern of cognitive decline from age 25 to 75 years in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).MethodsWe applied latent process mixed models to data obtained from patients with CADASIL who were repeatedly scored during their follow-up using 16 selected clinical scales or cognitive tests.ResultsThe modeled evolutions of these scores obtained from 1,243 observations in 265 patients recruited at the French National Referral Centre (50.1 years on average and 45.3% men) showed wide and heterogeneous variations in amplitude along the age-related progression of the disease. Although the Backward Digit Span remained essentially stable, a linear deterioration of scores obtained using the Symbol Digit Numbers or Number of Errors of Trail Making Test B was detected from 25 to 75 years. By contrast, the largest score changes were observed at midlife using the Digit Cancellation Task. All other tests related to executive functions, memory performances, or global cognitive efficiency showed a rate of change accelerating especially at the advanced stage of the disease. Male gender and the presence of gait disorders or of some disability at baseline were found to predict earlier or large changes of 4 scores (Index of Sensitivity to Cueing, Delayed Total Recall, Initiation/Perseveration, and Barthel Index) in a subgroup of individuals distinct from the rest of the sample.DiscussionCognitive alterations develop heterogeneously during the progression of CADASIL and vary largely according to the stage of the disease. These results suggest that not only the target population and study duration but also the stage of disease progression should be considered in preparing future clinical trials aimed at reducing cognitive decline in any such condition.

The Clinical Impact of Methotrexate-Induced Stroke-Like Neurotoxicity in Paediatric Departments: An Italian Multi-Centre Case-Series.

IntroductionStroke-like syndrome (SLS) is a rare subacute neurological complication of intrathecal or high-dose (≥500 mg) Methotrexate (MTX) administration. Its clinical features, evoking acute cerebral ischaemia with fluctuating course symptoms and a possible spontaneous resolution, have elicited interest among the scientific community. However, many issues are still open on the underlying pathogenesis, clinical, and therapeutic management and long-term outcome.Materials and MethodsWe retrospectively analyzed clinical, radiological and laboratory records of all patients diagnosed with SLS between 2011 and 2021 at 4 National referral centers for Pediatric Onco-Hematology. Patients with a latency period that was longer than 3 weeks between the last MTX administration of MTX and SLS onset were excluded from the analysis, as were those with unclear etiologies. We assessed symptom severity using a dedicated arbitrary scoring system. Eleven patients were included in the study.ResultsThe underlying disease was acute lymphoblastic leukemia type B in 10/11 patients, while fibroblastic osteosarcoma was present in a single subject. The median age at diagnosis was 11 years (range 4–34), and 64% of the patients were women. Symptoms occurred after a mean of 9.45 days (± 0.75) since the last MTX administration and lasted between 1 and 96 h. Clinical features included hemiplegia and/or cranial nerves palsy, paraesthesia, movement or speech disorders, and seizure. All patients underwent neuroimaging studies (CT and/or MRI) and EEG. The scoring system revealed an average of 4.9 points (± 2.3), with a median of 5 points (maximum 20 points). We detected a linear correlation between the severity of the disease and age in male patients.ConclusionsSLS is a rare, well-characterized complication of MTX administration. Despite the small sample, we have been able to confirm some of the previous findings in literature. We also identified a linear correlation between age and severity of the disease, which could improve the future clinical management.

Effects of the COVID-19 pandemic on the management of ST-Segment elevation myocardial infarction in Indonesia: a cohort study.

Background: ST-segment elevation myocardial infarction (STEMI) is a form of acute coronary syndrome with high mortality rate. Management of STEMI should be performed as soon as possible to prevent further damage. With the emergence of coronavirus disease 2019 (COVID-19), it may face obstacles. To overcome those problems, some changes in policy focusing on fibrinolytic therapy in STEMI patients have been applied. This study aimed to identify the effects of COVID-19 in management of STEMI patients in Indonesia. Methods: This retrospective study was conducted in Dr. Cipto Mangunkusumo Hospital (CMH), the national referral center in Indonesia. We compared data between 2018 to 2019 and 2020 to 2021 as before and during COVID-19 pandemic period, respectively. We analyzed the effects of COVID-19 on STEMI patients' visits to hospital i.e., monthly hospital admission and symptoms-to-hospital, management of STEMI i.e., the strategies and time of reperfusion, and clinical outcomes of STEMI patients i.e., major adverse coronary event and mortality. Results: There was a significant statistically reduced mean of monthly hospital admissions from 11 to 7 (p = 0.002) and prolonged duration of symptoms-to-hospital during COVID-19 from 8 to 12 hours (p = 0.005). There was also a decrease in primary percutaneous coronary intervention (PPCI) procedures during COVID-19 (65.2% vs. 27.8%, p<0.001), which was accompanied by an increased number of fibrinolytic (1.5% vs. 9.5%, p<0.001) and conservative therapy (28.5% vs. 55.6%, p <0.01). Moreover, there was also a prolonged duration of diagnosis-to-wire-crossing time (160 vs. 186 minutes, p = 0.005), meanwhile, percentage of urgent PCI, door-to-needle time, and clinical outcomes were not statistically significant. Conclusions: During COVID-19 pandemic, the number STEMI patients declined in monthly hospital admission, delays in symptoms-to-hospital time, changes in type of reperfusion strategy, and delays in PPCI procedures in CMH. Meanwhile, fibrinolytic time and clinical outcomes were not affected.

Pericarditis and Autoinflammation: A Clinical and Genetic Analysis of Patients With Idiopathic Recurrent Pericarditis and Monogenic Autoinflammatory Diseases at a National Referral Center.

BackgroundIdiopathic recurrent pericarditis (IRP) is an orphan disease that carries significant morbidity, partly driven by corticosteroid dependence. Innate immune modulators, colchicine and anti‐interleukin‐1 agents, pioneered in monogenic autoinflammatory diseases, have demonstrated remarkable efficacy in trials, suggesting that autoinflammation may contribute to IRP. This study characterizes the phenotype of patients with IRP and monogenic autoinflammatory diseases, and establishes whether autoinflammatory disease genes are associated with IRP.Methods and ResultsWe retrospectively analyzed the medical records of patients with IRP (n=136) and monogenic autoinflammatory diseases (n=1910) attending a national center (London, UK) between 2000 and 2021. We examined 4 genes (MEFV, MVK, NLRP3, TNFRSF1A) by next‐generation sequencing in 128 patients with IRP and compared the frequency of rare deleterious variants to controls obtained from the Genome Aggregation Database. In this cohort of patients with IRP, corticosteroid dependence was common (39/136, 28.7%) and was associated with chronic pain (adjusted odds ratio 2.8 [95% CI, 1.3–6.5], P=0.012). IRP frequently manifested with systemic inflammation (raised C‐reactive protein [121/136, 89.0%] and extrapericardial effusions [68/136, 50.0%]). Pericarditis was observed in all examined monogenic autoinflammatory diseases (0.4%–3.7% of cases). Rare deleterious MEFV variants were more frequent in IRP than in ancestry‐matched controls (allele frequency 9/200 versus 2932/129 200, P=0.040).ConclusionsPericarditis is a feature of interleukin‐1 driven monogenic autoinflammatory diseases and IRP is associated with variants in MEFV, a gene involved in interleukin‐1β processing. We also found that corticosteroid dependence in IRP is associated with chronic noninflammatory pain. Together these data implicate autoinflammation in IRP and support reducing reliance on corticosteroids in its management.

SURG-16. Pediatric oncology neurosurgery, four years after centralization in the Princess Máxima Center

Abstract INTRODUCTION: In 2018, the Princess Máxima Center officially opened its doors as a national referral center for pediatric oncology in the Netherlands. This centralization of pediatric oncology also reshaped the pediatric neurosurgery landscape. Almost four years after centralization it is time to make up the balance. METHODS: From the start in May 2018, a predesigned database was kept for all neurosurgical procedures performed in the Princess Máxima Center, Utrecht. Data was collected by a well-trained medical student and under close supervision of a pediatric neurosurgeon. Patient demographic data, tumor data (location, pathology), surgical data (approach, intended and obtained extent of resection), radiology data, and follow up data (complications, functional outcome) were collected. PRELIMINARY RESULTS: From May 2018 to December 2021, 783 oncology related surgeries have been performed in 472 individual patients (56% male; mean age 8 years). There were 316 cranial tumor resections, 279 of which were first resections. Pilocytic astrocytoma was the most frequent diagnosis (38%), followed by medulloblastoma (14%) and ependymoma (11%). Among the more rare tumors there were 29 diffuse midline gliomas and 29 craniopharyngiomas, reflecting the high volume after centralization. The extent of tumor resection and Clavien Dindo complication grading are correlated to time after centralization. CONCLUSION: Four years after the start of centralization, the pediatric oncology neurosurgery service in the Netherlands is well established. Clustering has resulted in high absolute numbers, even for rare tumor types, and growing experience. With this series we hope to create an international benchmark for pediatric oncology neurosurgery.

Abstract No. 273 Balloon pulmonary angioplasty in patients with non-operable or residual chronic thromboembolic hypertension: initial 5-year experience in a national referral center

Balloon pulmonary angioplasty (BPA) has become an emerging and complementary strategy for chronic thromboembolic hypertension (CTEPH) patients who are not suitable for pulmonary endarterectomy (PEA) or present recurrent symptoms after PEA. The purpose of our study was to evaluate the efficacy and safety of BPA in patients with non-operable or residual CTEPH during the initial 5-year experience in a single national referral center.

Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers' Perspectives.

The concept of customer satisfaction is gaining hold in all corporate sectors worldwide, and a satisfaction survey is used as a tool to discover service problems and as a chance for customers to rate their experience with health care services. A high degree of patient satisfaction with the services given has been found in numerous studies conducted in Malaysian public health care facilities. However, there is limited information available on caregiver satisfaction with pediatric clinics run by the Ministry of Health (MoH) of Malaysia. This was the first research performed at a public hospital's pediatric clinic, which was the first hospital to adopt the public-private-partnership model under the MoH, with the aim of discovering the prevalence and factors affecting the satisfaction of caregivers at the national referral center. Cross-sectional research using the standard self-administered SERVQUAL questionnaire was conducted among caregivers accompanying their children to the clinic. The questionnaire consists of 16 paired statements to evaluate their expectations and experiences with the clinic services. A total of 459 caregivers were involved in this study with a majority aged between 30 and 39 years (n=254, 55.4%). Caregivers from the Indian community (adjusted odds ratio [AOR] 2.91, 95% CI 1.37-6.18) and lower income groups (AOR 2.94, 95% CI 1.87-4.64), and those with lower educational backgrounds (AOR 3.58, 95% CI 1.19-10.72) were more likely to be satisfied with the quality of pediatric clinic services. Housewives/househusbands (AOR 0.48, 95% CI 0.25-0.90), on the other hand, appeared less likely to be satisfied with the services provided during their visit to the clinic. Looking at overall patient satisfaction, 50.5% (n=232) of caregivers demonstrated satisfaction with the quality of services, compared to 49.5% (n=227) of dissatisfied respondents. This paper suggests that, although most caregivers are satisfied with the services, greater emphasis must be placed on delivering reliable service in response to the MoH's mission to provide quality and integrated people-centered health services in Malaysia.

Peer Review of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Peer Review of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Peer Review of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Peer Review of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Authors’ Response to Peer Reviews of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Authors’ Response to Peer Reviews of “Satisfaction With Health Care Services at the Pediatric Specialist Clinic of the National Referral Center in Malaysia: Cross-sectional Study of Caregivers’ Perspectives”

Screening and management of bladder and bowel dysfunction in general pediatric outpatient clinic: a prospective observational study

BackgroundBladder and bowel dysfunction (BBD) is a common disorder in children that is often associated with psychosocial and behavioral problems. Data specific to BBD in Asian children are comparatively scarce. Accordingly, this study aimed to investigate the prevalence of BBD and the response to standard urotherapy among Thai children attending the general pediatric outpatient clinic of Siriraj Hospital – Thailand’s largest national tertiary referral center. MethodsChildren aged 4–12 years were recruited to complete the Dysfunctional Voiding Symptom Score (DVSS) questionnaire to screen for BBD during 2018 to 2020. Standard urotherapy, which consists of education and behavior management, was prescribed to those with a DVSS score that suggests the presence of BBD. Enrolled children and their caregivers were followed-up at 3 and 6 months. The Strengths and Difficulties Questionnaire (SDQ) was completed at baseline. DVSS scores at baseline, and at 3 months and 6 months after standard urotherapy were compared using repeated measures analysis of variance (ANOVA).ResultsA total of 1,042 children completed the DVSS during the study period, and 90 (8.6%) were deemed to have BBD. The mean age of BBD children was 6.9 ± 2.2 years, and the female to male ratio was 2.9:1. The most common symptoms were defecation frequency (80.0%), difficult defecation (80.0%), curtsying (74.4%), urgency (68.9%), infrequent voiding (43.3%), and daytime incontinence (32.2%). Forty-one BBD children completed the SDQ, and 32.5% had scores suggestive of hyperactivity problems. Among the 24 BBD patients who were followed-up after 3 and 6 months of standard urotherapy, there was a significant improvement in DVSS results (9.5 ± 3.1 at baseline vs. 6.9 ± 3.4 at 3 months vs. 4.4 ± 3.9 at 6 months; p < 0.01). Nine of 12 patients with urinary incontinence showed complete response at 6 months. The overall Bristol stool score significantly improved from 2.6 ± 0.7 at baseline to 3.2 ± 1.0 at 6 months (p = 0.03).ConclusionsBBD is a prevalent condition among Thai children that is often associated with emotional and behavioral problems. Standard urotherapy prescribed in a general pediatric outpatient clinic setting yielded favorable outcomes in Thai children with BBD.