Information ranks highest: Expectations of female adolescents with a rare genital malformation towards health care services

Background

Access to highly specialized health care services and support to meet the patient’s specific needs is critical for health outcome, especially during age-related transitions within the health care system such as with adolescents entering adult medicine. Being affected by an orphan disease complicates the situation in several important respects. Long distances to dedicated institutions and scarcity of knowledge, even among medical doctors, may present major obstacles for proper access to health care services and health chances. This study is part of the BMBF funded TransCareO project examining in a mixed-method design health care provisional deficits, preferences, and barriers in health care access as perceived by female adolescents affected by the Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), a rare (orphan) genital malformation.

Methods

Prior to a communicative validation workshop, critical elements of MRKHS related care and support (items) were identified in interviews with MRKHS patients. During the subsequent workshop, 87 persons involved in health care and support for MRKHS were asked to rate the items using a 7-point Likert scale (7, strongly agree; 1, strongly disagree) as to 1) the elements’ potential importance (i.e., health care expected to be “best practice”, or priority) and 2) the presently experienced care. A gap score between the two was computed highlighting fields of action. Items were arranged into ten separate questionnaires representing domains of care and support (e.g., online-portal, patient participation). Within each domain, several items addressed various aspects of “information” and “access”. Here, we present the outcome of items’ evaluation by patients (attended, N_PAT = 35; respondents, N_RESP = 19).

Results

Highest priority scores occurred for domains “Online-Portal”, “Patient participation”, and “Tailored informational offers”, characterizing them as extremely important for the perception as best practice. Highest gap scores yielded domains “Tailored informational offers”, reflecting perceived lack of disease-related information for affected persons, medical experts, and health insurance companies, “Online-Portal” (with limited information available on specialist clinics and specialized doctors), and regarding insufficient support offers (e.g., in school and occupational settings). Conversely, lowest gap scores were found with group offers for MRKHS patients (“Transition programs”) and MRKHS self-help days (“Patient participation”), suggesting satisfaction or good solutions in place.

Discussion

The importance assigned to disease-related information indicates that informational deficits are perceived by patients as barriers, hindering proper access to health care, especially in an orphan disease. Access to health-related information plays a role for all persons seeking help and care. However, the overwhelmingly high scores attributed to these elements in the context of an orphan disease reveal that here improved information policies are crucial, demanding for institutionalized solutions supported by the health care system.

Implications for practice

The disparity between experience of care and attribution as best practice detected describes areas of action in all domains involved, highlighting information related fields. New concepts and structures for health care in orphan diseases could draw upon these patient-oriented results a) regarding orphan-disease specific elements demanding institutionalized reimbursement, b) essential elements for center care and corresponding networks, and c) elements reflecting patients´ participation in the conception of centers for rare diseases.

[Mayer-Rokitansky-Küster-Hauser syndrome]

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital anomaly characterized by uterovaginal agenesis in females with normal secondary sex characteristics and normal karyotype (46,XX). The prevalence of MRKH syndrome is one in 5,000 live female births as recently confirmed by a nationwide population-based study in Denmark. This review kaleidoscopically summarizes the current knowledge of the history, genetics, diagnostics, treatment of vaginal agenesis, psychosexual aspects, and fertility options in MRKH syndrome.

Clinical spectrum of children receiving palliative care in Malaysian Hospitals

INTRODUCTION

Awareness for paediatric palliative care has resulted in the impetus for paediatrician-led palliative care services across Malaysia. However, there is paucity of local data on patients receiving hospital-based paediatric palliative care. We aim to review the clinical spectrum of patients referred to these services.

METHODS

An observational study of children aged between 0-18 years receiving palliative care at 13 hospitals between 1st January and 31st December 2014 was carried out.

RESULTS

There were 315 patients analysed, 90 (28.6%) and 46 (14.6%) were neonates and adolescents respectively. The main ICD-10 diagnostic categories for all patients were identified to be 'Congenital malformations, deformations and chromosomal abnormalities' 117 (37.1%), 'Diseases of nervous system' 76 (24.1%) and 'Neoplasms' 60 (19.0%). At referral 156 (50%) patients had holistic needs assessments. Patients with 'Diseases of nervous system' were assessed to have significantly more physical needs than the other two diagnostic categories. Majority of patients who knew of their diagnosis and prognosis were those with malignancy. Over a fifth of referrals were at their terminal admission. Of 144 who died, 111 (77.1%) had advanced care plans. There was bereavement follow-up in 98 (68.1%) patients.

CONCLUSION

Patients referred for palliative care have varied diagnoses and needs. To ensure all paediatricians are competent to deliver quality care to all children, further education and training initiatives is imperative.

Inpatient Hospitalization Costs Associated with Birth Defects Among Persons of All Ages - United States, 2013

In the United States, major structural or genetic birth defects affect approximately 3% of live births (1) and are responsible for 20% of infant deaths (2). Birth defects can affect persons across their lifespan and are the cause of significant lifelong disabilities. CDC used the Healthcare Cost and Utilization Project (HCUP) 2013 National Inpatient Sample (NIS), a 20% stratified sample of discharges from nonfederal community hospitals, to estimate the annual cost of birth defect-associated hospitalizations in the United States, both for persons of all ages and by age group. Birth defect-associated hospitalizations had disproportionately high costs, accounting for 3.0% of all hospitalizations and 5.2% of total hospital costs. The estimated annual cost of birth defect-associated hospitalizations in the United States in 2013 was $22.9 billion. Estimates of the cost of birth defect-associated hospitalizations offer important information about the impact of birth defects among persons of all ages on the overall health care system and can be used to prioritize prevention, early detection, and care.

Patient-Centred Design of Healthcare Services: Meaningful Events as Basis for Patient Experiences of Families

Patient experience has become a crucial part of the quality of any healthcare service. Experiences and their structures are not however trivial phenomena that are easy to describe and model. Instead, subjective and dynamic experiences seem to escape definitions and measurements. In order to map the dimensions and dynamics of patient experiences of families, i.e. experiences in families where one or more children are or have been seriously ill, we conducted in depth interviews with 17 parents. Both the interview structure and analysis were based on the technology as experience framework, which states that products and services are not just used but lived with. The results of our study describe patient experiences that are rich and complex yet structurally similar in their manifestations and development. Event-based and situational patient experience emerges through meaningful events relating to the patient's illness. The experiences evolve through new events as well as patient's reflections on past events and in the framing of the current situation. The presented situational patient experience model can be utilized to evaluate and design healthcare services.

Health Care for Certain Children of Vietnam Veterans and Certain Korea Veterans--Covered Birth Defects and Spina Bifida. Final rule

This rule adopts as final a proposed rule of the Department of Veterans Affairs (VA) to amend its regulations concerning the provision of health care to birth children of Vietnam veterans and veterans of covered service in Korea diagnosed with spina bifida, except for spina bifida occulta, and certain other birth defects. In the proposed rule published on May 15, 2015, VA proposed changes to more clearly define the types of health care VA provides, including day health care and health-related services, which we defined as homemaker or home health aide services that provide assistance with Activities of Daily Living or Instrumental Activities of Daily Living that have therapeutic value. We also proposed changes to the list of health care services that require preauthorization by VA. This final rule addresses comments received from the public and adopts as final the proposed rule, without change.

Averting the Legacy of Kidney Disease--Focus on Childhood

World Kidney Day 2016 focuses on kidney disease in childhood and the antecedents of adult kidney disease that can begin in earliest childhood. Chronic kidney disease (CKD) in childhood differs from that in adults, as the largest diagnostic group among children includes congenital anomalies and inherited disorders, with glomerulopathies and kidney disease in the setting of diabetes being relatively uncommon. In addition, many children with acute kidney injury will ultimately develop sequelae that may lead to hypertension and CKD in later childhood or in adult life. Children born early or who are small-for date newborns have relatively increased risk for the development of CKD later in life. Persons with a high-risk birth and early childhood history should be watched closely in order to help detect early signs of kidney disease in time to provide effective prevention or treatment. Successful therapy is feasible for advanced CKD in childhood; there is evidence that children fare better than adults, if they receive kidney replacement therapy including dialysis and transplantation, while only a minority of children may require this ultimate intervention. Because there are disparities in access to care, effort is needed so that those children with kidney disease, wherever they live, may be treated effectively, irrespective of their geographic or economic circumstances. Our hope is that World Kidney Day will inform the general public, policy makers and caregivers about the needs and possibilities surrounding kidney disease in childhood.

In Favour of Medical Dissensus: Why We Should Agree to Disagree About End-of-Life Decisions

End-of-life decision-making is controversial. There are different views about when it is appropriate to limit life-sustaining treatment, and about what palliative options are permissible. One approach to decisions of this nature sees consensus as crucial. Decisions to limit treatment are made only if all or a majority of caregivers agree. We argue, however, that it is a mistake to require professional consensus in end-of-life decisions. In the first part of the article we explore practical, ethical, and legal factors that support agreement. We analyse subjective and objective accounts of moral reasoning: accord is neither necessary nor sufficient for decisions. We propose an alternative norm for decisions - that of 'professional dissensus'. In the final part of the article we address the role of agreement in end-of-life policy. Such guidelines can ethically be based on dissensus rather than consensus. Disagreement is not always a bad thing.

[CONSERVATIVE TREATMENT OF MAYER-ROKITANSKY-KÜSTER-HAUSER SYNDROME. REVIEW OF LITERATURE AND OUR EXPERIENCE]

Mayer-Rokitansky-Küster-Hauser syndrome is a part of the group of abnormalities known as "Anomalies of the fusion of the Müllerian ducts". It is characterized by normal development of breasts and hairs, normal appearance of external genitalia, normal feminine genotype (46XX), normal FSH, LH, E₂ and Test. levels, normal ovaries and congenital absence of uterus and the whole or the upper two thirds of the vagina. It is observed in about 15% of the cases with primary amenorrhea and the incidence is about 1:4500-6000. Etiologycal factors such as lack of estrogen/gestagen receptors, deletions or mutations of genes that stop the fusion, as well as the activation of anti-Müllerian hormone (AMH), are considered. The etiology is being explored but there is no consensus yet. The diagnosis is confirmed during a clinical examination, which takes place because of a primary amenorrhea (often happening at the age of 16), and the absence of a uterus and vagina is proved. The therapy should be handled by a multidisciplinary team including obstetrician, trained midwife, psychologist, specialist in imaging and psycho-sexual counseling. The idea for surgical creation of vagina (neovagina) dates many years ago. The first known documents date back to 1817 and over the years a variety of methods are offered usage of amnion, dura mater, peritoneum, skin grafts, different parts of the intestine, cellulose, etc. The first method of non-surgical treatment is offered by the Czech gynecologist Frank. His ambition was to build a vagina by gradual dilatation of the tissue while applying dilatators with successively increasing length and thickness. The method was further developed by Ingram (1981) and nowadays by Edmonds (2012). He reported about 245 patients treated during the last 12 years by his team. 232 of them had a success in anatomic aspect (95%), 13 did not complete the treatment due to psychological or cultural problems. The experts from American College of Obstetricians and Gynecologists include in their "Committee Opinion" from May 2013 the following lines: "Non-surgical creation of the vagina is the appropriate first line approach in most patients". Briefly is presented our experience in this field--14 girls at the age of 16-18, successfully treated with dilatation in the III Gynecology Clinic in University hospital "Maichin dom", Sofia, Bulgaria.

[Mayer-Rokitansky-Küster-Hauser syndrome: two cases report]

Agenesia of the Müllerian ducts is a low-frequency congenital disease but with devastating effects on women's reproductive health. In this paper we present two cases of women affected by Mayer-Rokitansky-Küster-Hauser syndrome (MRKH). First case was a 17-year-old woman with aplasia of the upper vagina and absence of uterus. No other defects were found and was classified as type 1-MRKH. Second case was 18-year-old woman with absence of uterus, escoliosis and polycystic ovary syndrome, classified as type II-MRKH. Patients were seen at the Hospital with primary amenorrhea and fully developed secondary sexual characteristics. A clinical follow-up protocol, including the use of high-resolution image studies was used for diagnosis. Diagnostic procedures and current medical approaches to the treatment of MRKH are discussed, including psychological advisory, surgical procedures and new tissue-engineering techniques.

[Efficacy of softband Ponto in young children with bilateral congenital microtia with aural atresia]

OBJECTIVE

To evaluate auditory developments and the effectiveness of children with congenital bilateral aural atresia after using softband Ponto and to compare them with children with normal hearing.

METHOD

Twenty patients (age ranging from 3 months to 21 months ) with bilateral aural atresia were studied. The air and bone auditory thresholds were assessed by auditory brain stem response (ABR). The infant-todder meaning auditory integration scale (IT-MAIS) was used to evaluate the auditory development at three time levels: baseline, 3 months and 6 months.

RESULT

The average unaided bone conduction hearing thresholds of patients is (17.5 ± 5.9)dB nHL,and the average air conduction hearing thresholds is (72.5 ± 9.3)dB nHL. The average VRA hearing thresholds of 5 patients is (30.5 ± 5.9) dB HL. The IT-MAIS total, detection and perception scores are improved specifically after wearing softband Ponto and approaching the normal level.

CONCLUSION

Softband Ponto is suitable for infants with bilateral atresia. Results from these auditory development testing are encouraging. Softband Ponto should be used as a bridge for surgical implantations when temporal bone is thick enough.

eHealth Services for the European Reference Network on Rare Anaemias (eENERCA)

This paper presents an electronic registry system for the purposes of the eENERCA for rare congenital conditions that require lifelong follow up and treatment. The main objective of the eENERCA project focusses on the prevention of major rare anaemias (RAs) by facilitating the access, at a European level, to the best genetic counselling, diagnosis and clinical management of the patients with RA independently of their country of origin. This can be achieved by promoting an extension of the full Electronic Health Record system and specifically the electronic registries for RAs, across Europe for the purposes stated hence promoting service development for the benefit of patients. The proposed eRegistry will serve as an epidemiological tool to improve the management of patient services and ultimately improve patient care.

Clinical findings and survival in 56 sick neonatal New World camelids

BACKGROUND

Information pertaining to clinical presentation and outcome of neonatal New World camelids (NWC) is limited when compared to calves and foals.

HYPOTHESIS

Values of variables at admission and subsequent treatment would predict survival in sick neonatal NWC.

ANIMALS

Fifty-six client-owned sick neonatal NWC presented over a 10-year period to the Purdue University Veterinary Teaching Hospital.

METHODS

A retrospective study was performed. Inclusion criteria were NWC less than 30 days of age with complete medical records that presented between 2000 and 2010.

RESULTS

The median age at presentation was 1 day (range 1-20). The most common diagnoses were systemic inflammatory response syndrome (50%), congenital defects (41%), ophthalmic lesions (21%), sepsis (16%), and gastrointestinal diseases (16%). Sixty-six percent of NWC survived to discharge. Clinicopathologic findings on admission were variable and not specific for disorders. Factors associated with survival were absence of choanal atresia (P = .001, OR: 55.9 [2.5-1,232]), administration of llama plasma (P = .013, OR: 4.9 [1.4-17.7]), and antimicrobial treatment with trimethoprim-sulfamethoxazole (TMS) (P = .016, OR: 6.5 [1.3-32.2]).

CONCLUSIONS AND CLINICAL IMPORTANCE

The use of antibiotics, particularly TMS, and llama plasma are recommended in sick neonatal NWC. Results from this study could contribute toward defining a NWC-specific sepsis scoring system.

Decision-making in classic trigeminal neuralgia concurrent with a pontine cavernous malformation: Causal or coincidental association?

Trigeminal neuralgia is classically associated with neurovascular compression of the trigeminal nerve, at the root entry zone (REZ). However, patients are occasionally affected by intra-axial involvement of trigeminal sensory fibers caused by demyelinating diseases, strokes and, rarely, pontine cavernous malformations. We discuss the management strategies and decision-making process in a 55-year-old patient, affected by trigeminal neuralgia with 2 potential causative mechanisms: a neurovascular conflict at the trigeminal REZ and an ipsilateral cavernous malformation at the pontine nucleus of the trigeminal nerve.

Low inter-arytenoid height: a subclassification of type 1 laryngeal cleft diagnosis and management

OBJECTIVE

To report our experience of patients with type 1 laryngeal cleft, (including low inter-arytenoid height) who failed conservative management over a five year period. We describe the diagnostic elements of the history, examination at laryngobronchoscopy and provide a management algorithm including the use of inter-arytenoid submucosal injection of gelfoam as a temporary therapeutic as well as diagnostic tool.

METHODS

A retrospective case note review over a five year period was undertaken to review all cases of type 1 laryngeal cleft who failed conservative management. Presenting symptoms, diagnostic procedures, surgical interventions and clinical outcomes were reviewed.

RESULTS

Seventeen patients were identified. Chronic cough was the most consistent feature in the history (100%). All patients underwent a microlaryngoscopy with binocular microlaryngeal assessment. Six patients (35%) underwent gelfoam injection; four of these went on to a formal repair. The remaining 11 all had a repair performed without injection. The success of surgical repair was 80% (12/15) however in the other three, all had improvement in symptoms.

CONCLUSIONS

Type 1 laryngeal cleft anomalies may extend beyond that described by Benjamin and Inglis. An appropriate history as well as binocular inspection at the time of laryngoscopy is essential. Injection augmentation offers a safe tool in the assessment and management, and endoscopic surgical repair remains the standard for definitive therapy in those that fail conservative management.

[Laryngomalacia: principal cause of stridor in infants and small children]

Laryngomalacia (LM) is the most common cause of congenital stridor. It is caused by obstruction of the upper airway by collapse of redundant supraglottic tissues during inspiration. In the management of a child with congenital stridor, it is important to rule out other malformations of the upper airway that could mimic or be synchronous with LM. Symptoms of LM are usually mild and disappear spontaneously by 2 years. About 20% of patients with LM may have extreme symptoms (severe stridor, feeding difficulties and growth retardation) requiring treatment by endoscopic surgery (supraglottoplasty), which has an excellent success rate with little risk of recurrence and complications.

Hearing stimulation of the pediatric patient with congenital aural atresia: surgical and audiological evaluation of 38 patients

The aim of this work is to stress the importance of and discuss the timing and options for the treatment of congenital aural atresia (CAA), including non-surgical alternative treatment modalities and amplification, and to report the audiological and surgical results of a series of patients. Thirty-eight children with CAA were evaluated with regard to hearing and anatomical anomalies accompanying CAA: the state of the ossicles and the facial nerve, postoperative complications and audiological results. The ages of the patients ranged between 4 and 18 years, with a mean of 10 years. All underwent surgical treatment; 32 had unilateral atresia, while 6 had bilateral atresia. The mean follow-up duration was 7 months. The facial canal was dehiscent in 36.8% of cases. In 70.2% cases, the malleus and incus were present as an ossicular mass, fixed and attached to the atretic bone. The stapes was normal in 97.3% of the patients; in 2.7% the suprastructure was deformed. The success rate, defined as an air-bone gap of 20 dB or less, was 63.1% in this series of patients. If atresia is bilateral, very early hearing stimulation to prevent the maldevelopment of children's speech and cognitive skills is of the utmost importance. In unilateral cases, surgery may be postponed until early adulthood, when the patient is able to make his/her own decision and cooperate in the treatment and postoperative aspects.