Home  About us  Contact
 

Tertiary Referrals (tertiary + referral)

Distribution by Scientific Domains
Medical Sciences85%

Terms modified by Tertiary Referrals

  • tertiary referral center
    		•
  • tertiary referral centre
    		•
  • tertiary referral hospital
    		•

    Selected Abstracts

    RISKS AND CONSEQUENCES OF INCIDENTAL PARATHYROIDECTOMY DURING THYROID RESECTION

    ANZ JOURNAL OF SURGERY, Issue 1-2 2007
    Rebecca S. Sippel
    Background: Inadvertent removal of the parathyroid glands during elective thyroid surgery occurs more frequently in certain high-risk patients and can lead to symptomatic hypocalcaemia. Methods: A case,control study was carried out at a tertiary referral, academic medical centre between May 1994 and August 2001. Five hundred and thirteen patients underwent thyroid resection. Pathology reports were reviewed to identify patients who had the inadvertent removal of a parathyroid gland during their thyroid surgery. Thirty-three (6.4%) patients had inadvertent resection of a parathyroid gland. The outcomes of these 33 patients (INCIDENTAL) were compared with the other 480 patients who did not have resection of parathyroid tissue (NO INCIDENTAL). Results: Risk factors for inadvertent parathyroid resection included younger age (P = 0.003), bilateral thyroid resection (P = 0.001) and malignant pathology (P = 0.002). Factors that did not increase the risk of incidental parathyroidectomy included gland weight, sex, presence of a goitre, previous neck exploration and concurrent lymph node dissection. In the INCIDENTAL group 24% had a postoperative calcium levels less than 7.0 mg/dL (P = 0.001). Symptomatic hypocalcaemia developed in 12% of INCIDENTAL patients, compared to 4% in the NO INCIDENTAL group (P = 0.06). Conclusion: Incidental removal of parathyroid tissue occurred in 6.4% of thyroid resections. Younger patients undergoing a total or subtotal thyroidectomy for malignancy were at the highest risk. These patients had lower postoperative calcium levels, but the majority (88%) experienced no clinical consequences. [source]

    Morbidity of incontinence surgery in women over 70 years old: a retrospective cohort study

    BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 6 2005
    Harriet Pugsley
    Objective To compare the success rate and complications after colposuspension and tension-free vaginal tape (TVT) insertion in women aged 70 years or more compared with younger women. Design A retrospective study of patients having surgery between November 2000 and October 2002. Setting A tertiary referral, academic urogynaecology unit in a University teaching hospital. Population Two hundred and twenty-six women having surgical treatment for urinary incontinence. Methods Data on cure/improvement and complications were extracted from the notes. Patients were grouped by age at surgery and the odds ratios (OR) and 95% confidence intervals (CI) for each outcome were calculated. Main outcome measures Subjective cure rate and the incidence of complications by age group. Results One hundred and three patients had colposuspension, 11 (10.7%) aged 70 or more. One hundred and twenty-three patients had TVT insertions, 23 (18.7%) aged 70 or more. The cure rate for each procedure was similar between age groups. After colposuspension, urinary tract infection (UTI; OR 11.33; 95% CI 2.61, 49.28) and long term self-catheterisation (percentage of difference 9.1; 95% CI 3.0, 15.2) were more common in women over 70. After TVT, repeat urodynamics (OR 3.91; 95% CI 1.11, 13.76), recurrent UTI (OR 4.22; 95% CI 1.03, 17.26) and tape division (OR 29.12; 95% CI 3.20, 264.86) were more common in older women. Conclusions Incontinence surgery carries a higher risk of complications in the elderly including UTI and voiding dysfunction. Extended antibiotic prophylaxis and intermittent self-catheterisation training should be offered to elderly women before surgery. [source]

    Mycotic keratitis: an overview of diagnosis and therapy

    MYCOSES, Issue 3 2008
    P. K. Shukla
    Summary The increased incidence of fungal infections in the recent past has been attributed to the increase in the number of human immunodeficiency virus-positive and AIDS patients. Early diagnosis of mycoses in patients is crucial for prompt antifungal therapy. The yield of clinical examination in the diagnosis of keratomycosis is 63,83% and KOH mount is 91%. This still highlights the limitation of routine clinical examination and smear examination, which is not performing 100% efficiently. It is for these 37%, 17% and 9% of cases, every day advanced technologies are called for. Those who deal with patient care are aware of certainties and uncertainties of results of clinical examination. The best reported figures at specialized centres might not translate into clinical practice. Another factor to be kept in mind is that many patients who come after secondary and tertiary referrals are already treated with antibiotics, antivirals, steroids and sometimes even antifungals that distort the clinical picture completely. Further, one has to consider as well the cases caused by yeast-like fungi, which resemble bacterial keratitis. Confirmation of diagnosis, not only in case of mycotic keratitis but also for other diseases, to initiate prompt and accurate therapy would avoid unnecessary and indiscriminate use of steroids/antibacterials/antivirals and antifungals. [source]

    Cost-effectiveness of prenatal screening for thalassaemia in Hong Kong

    PRENATAL DIAGNOSIS, Issue 11 2004
    K. Y. Leung
    Abstract Objectives To determine the cost effectiveness of a universal prenatal screening program for ,- and ,-thalassaemia. Methods We retrospectively reviewed our program from 1998 to 2002, and calculated the direct and indirect costs of various components. Results 18 936 women were screened at our prenatal clinic and 153 couples were subsequently referred to our Prenatal Diagnostic Centre for counselling and further investigations. In addition, there were 238 tertiary referrals and 157 self-referrals. After investigations, 84 fetuses were at risk of ,-thalassaemia major/,-E thalassaemia, 19 of them were affected and 18 were aborted. The total expenditure on our program (HK$10.0 million) would be less than the postnatal service costs (HK$40.4 million) for 18,-thalassaemia major fetuses if they were born. Of 361 women at risk of carrying a homozygous ,0 -thalassaemia fetus, 311 (86.2%) opted for the indirect approach (using serial ultrasound examinations to exclude Hb Bart's disease), and 76 (24.5%) subsequently underwent an invasive test for a definitive diagnosis. The sensitivity and false positive rate of this indirect approach was 100.0% and 2.9% respectively. Conclusion It is cost effective to run a universal prenatal screening program in an area where both ,-thalassaemia and ,-thalassaemia are prevalent. The indirect approach can effectively avoid an invasive test in unaffected pregnancies. Copyright © 2004 John Wiley & Sons, Ltd. [source]

    Early onset severe pre-eclampsia: expectant management at a secondary hospital in close association with a tertiary institution

    BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 1 2005
    Charl Oettle
    Objectives Early onset severe pre-eclampsia is ideally managed in a tertiary setting. We investigated the possibility of safe management at secondary level, in close co-operation with the tertiary centre. Design Prospective case series over 39 months. Setting Secondary referral centre. Population All women (n= 131) between 24 and 34 weeks of gestation with severe pre-eclampsia, where both mother and fetus were otherwise stable. Methods After admission, frequent intensive but non-invasive monitoring of mother and fetus was performed. Women were delivered on achieving 34 weeks, or if fetal distress or major maternal complications developed. Transfer to the tertiary centre was individualised. Main outcome measures Prolongation of gestation, maternal complications, perinatal outcome and number of tertiary referrals. Results Most women [n= 116 (88.5%)] were managed entirely at the secondary hospital. Major maternal complications occurred in 44 (33.6%) cases with placental abruption (22.9%) the most common. One maternal death occurred and two women required intensive care admission. A mean of 11.6 days was gained before delivery with the mean delivery gestation being 31.8 weeks. The most frequent reason for delivery was fetal distress (55.2%). There were four intrauterine deaths. The perinatal mortality rate (,1000 g) was 44.4/1000, and the early neonatal mortality rate (,500 g) was 30.5/1000. Conclusions The maternal and perinatal outcomes are comparable to those achieved by other tertiary units. This model of expectant management of early onset, severe pre-eclampsia is encouraging but requires close co-operation between secondary and tertiary institutions. Referrals to the tertiary centre were optimised, reducing their workload and costs, and patients were managed closer to their communities. [source]

    Inpatient management of psoriasis: a multicentre service review to establish national admission standards

    BRITISH JOURNAL OF DERMATOLOGY, Issue 2 2008
    A.L. Woods
    Summary Background, Some patients with psoriasis may require hospital admission to stabilize their condition, although the role of inpatient management is changing given recent advances in therapeutic options, emphasis on community-based care for chronic conditions and limited healthcare resources. There is a need for evidence-based national standards for inpatient management of psoriasis taking account of factors that predict length of stay. Objectives, To determine which factors predict length of stay for patients with psoriasis requiring inpatient hospital care with a view to setting evidence-based standards for inpatient psoriasis management. Methods, A multicentre service review was conducted on all psoriasis admissions over a 9-month period in four dermatology centres in the U.K. We collected data on admission, at discharge and, where possible, at 3 months following discharge. Psoriasis severity was assessed using four validated scoring systems, including Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index. We also recorded length of stay and treatment details. Results, Length of stay varied widely between the four centres, but was similar in the two centres which received a high proportion of tertiary referrals for severe psoriasis (mean 19·7 days, range 1,78, analysis of variance P = 0·002). Disease severity, measured by PASI, on admission (mean 15·7, interquartile range 8·3,20·8) was significantly higher in the tertiary centres (P < 0·0001). However, there was no significant difference in PASI between centres on discharge. The admission PASI was significantly associated with length of stay (r = 0·2, P = 0·02). There was no significant correlation between other measures of disease severity and length of stay. Conclusions, Disease severity on admission for patients with psoriasis is greater in tertiary referral centres for psoriasis and is directly associated with length of stay. Length of stay should be used in conjunction with clinical measures such as PASI improvement to set national standards for quality in secondary care. [source]

    Management of severe adult atopic dermatitis

    CLINICAL & EXPERIMENTAL DERMATOLOGY, Issue 4 2002
    Nicholas Reynolds
    In common with many units, we run a specialist atopic eczema clinic that receives both secondary and tertiary referrals. Investigation into possible provoking factors includes RAST testing and patch testing where appropriate. The mainstay of treatment for moderate to severe atopic eczema remains topical steroids and emollients. Our specialist nurses play a key role in education and in particular demonstrating topical treatments , including bandaging. It is surprising that many patients have not previously been shown how to apply the treatments prescribed. Nevertheless, despite optimizing topical treatment protocols, a proportion of patients require hospital admission or second-line therapy. Our recent double-blind, randomized, controlled trial of narrow-band UVII vs. UVA (as used in PUVA) vs. placebo has confirmed that narrow-band WB phototherapy is an effective adjunctive treatment in moderate to severe atopic eczema. This trial also highlighted the value of recording disease activity (e.g. SASSAD) in individual patients following a change of therapy. UVA1 may be useful for acute severe atopic eczema but this UV source is only available in limited centres within the UK. Selected resistant patients or patients with acute flares are considered for short-term cyclosporin therapy. Azathioprine is widely used by consultant dermatologists in the UK as a second-line agent , despite the lack of evidence of efficacy. We are currently conducting a randomized placebo-controlled trial to address this issue. The importance of checking thiopurine methyl transferase (TPMT) prior to initiating azathioprine therapy has been emphasized. Our pilot data, with a dosage regime based on the TPMT result, suggest that patients may achieve a longer-term remission after a relatively short course. Mycophenolate mofetil has been reported to be effective in an open trial and methotrexate is also used but there is a lack of published evidence. The advent of topical tacrolimus and ascomycins, which have been shown to be effective in controlled trials, appear to be a promising development in the management of patients with moderate to severe atopic eczema and may lead to reduction in the use of systemic agents. [source]