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Söderström L, Gunnarsdottir A, Oddsberg J, Svensson PJ, Wester T, Granström AL. National Centralization of Hirschsprung's Disease in Sweden:A Comparison of Preoperative Management and Outcomes. J Pediatr Surg 2024:S0022-3468(24)00308-7. [PMID: 38871619 DOI: 10.1016/j.jpedsurg.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Surgical treatment of Hirschsprung's disease (HSCR) in Sweden was centralized to two tertiary pediatric surgery centers 1st of July 2018. Although complex surgical care in adults seems to benefit from centralization there is little evidence to support centralization of pediatric surgical care. The aim of this study was to assess centralization of HSCR in Sweden, with special consideration to preoperative management and outcomes in this group of patients. METHODS This study retrospectively analyzed data of patients with HSCR that had undergone or were planned to undergo pull-through at our center, from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 were compared with patients managed from 1st of July 2018 to 30th of June 2023 regarding diagnostic procedures, preoperative treatment, complications and time to definitive surgery. RESULTS Thirty-six patients were managed during the first five-year period compared to 57 during the second period. There was an increased number of patients referred from other Swedish regions to our center following the centralization. Time from diagnosis to pull-through increased from 33 to 55 days after centralization. There were no significant differences in pre-operative management or complications, general or related to stoma. CONCLUSIONS Despite increasing patient volumes and longer time from diagnosis to pull through, centralization of care for HSCR does not seem to change the preoperative management and risk of complications. With access to support from the specialist center, transanal irrigations remain a safe mode of at home management until surgery, regardless of distance to index hospital. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Linnea Söderström
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
| | - Anna Gunnarsdottir
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jenny Oddsberg
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Pär-Johan Svensson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Wester
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Löf Granström
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
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Coppola E, Sgrulletti M, Cortesi M, Romano R, Cirillo E, Giardino G, Dotta L, Cancrini C, Bruzzese D, Badolato R, Moschese V, Pignata C. The Inborn Errors of Immunity-Virtual Consultation System Platform in Service for the Italian Primary Immunodeficiency Network: Results from the Validation Phase. J Clin Immunol 2024; 44:47. [PMID: 38231401 PMCID: PMC10794402 DOI: 10.1007/s10875-023-01644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/17/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE Inborn errors of immunity (IEI) represent a heterogeneous group of rare genetically determined diseases. In some cases, patients present with complex or atypical phenotypes, not fulfilling the accepted diagnostic criteria for IEI and, thus, at high risk of misdiagnosis or diagnostic delay. This study aimed to validate a platform that, through the opinion of immunologist experts, improves the diagnostic process and the level of care of patients with atypical/complex IEI. METHODS Here, we describe the functioning of the IEI-Virtual Consultation System (VCS), an innovative platform created by the Italian Immunodeficiency Network (IPINet). RESULTS In the validation phase, from January 2020 to June 2021, 68 cases were entered on the IEI-VCS platform. A final diagnosis was achieved in 35/68 cases (51%, 95% CI 38.7 to 64.2). In 22 out of 35 solved cases, the diagnosis was confirmed by genetic analysis. In 3/35 cases, a diagnosis of secondary immunodeficiency was made. In the remaining 10 cases, an unequivocal clinical and immunological diagnosis was obtained, even though not substantiated by genetic analysis. CONCLUSION From our preliminary study, the VCS represents an innovative and useful system to improve the diagnostic process of patients with complex unsolved IEI disorders, with benefits both in terms of reduction of time of diagnosis and access to the required therapies. These results may help the functioning of other international platforms for the management of complex cases.
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Affiliation(s)
- Emma Coppola
- Section of Pediatrics, Department of Translational Medical Sciences, Federico II University, Via S. Pansini, 5-80131, Naples, Italy
| | - Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
- PhD Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Manuela Cortesi
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Roberta Romano
- Section of Pediatrics, Department of Translational Medical Sciences, Federico II University, Via S. Pansini, 5-80131, Naples, Italy
| | - Emilia Cirillo
- Section of Pediatrics, Department of Translational Medical Sciences, Federico II University, Via S. Pansini, 5-80131, Naples, Italy
| | - Giuliana Giardino
- Section of Pediatrics, Department of Translational Medical Sciences, Federico II University, Via S. Pansini, 5-80131, Naples, Italy
| | - Laura Dotta
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Caterina Cancrini
- Research Unit of Primary Immunodeficiency, IRCCS Bambin Gesù Children Hospital, Rome, Italy
| | - Dario Bruzzese
- Department of Public Health, Federico II University, Naples, Italy
| | - Raffaele Badolato
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, ASST- Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, Rome, Italy
| | - Claudio Pignata
- Section of Pediatrics, Department of Translational Medical Sciences, Federico II University, Via S. Pansini, 5-80131, Naples, Italy.
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Cohen-Cutler S, Blatt J, Bayliff S, Iacobas I, Hammill A, Sisk BA. Vascular Anomalies Care in the United States: A Cross-Sectional National Survey. J Pediatr 2023; 261:113579. [PMID: 37353145 DOI: 10.1016/j.jpeds.2023.113579] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To characterize the current distribution, composition, and practice patterns of multidisciplinary vascular anomalies (VAs) teams in the US. STUDY DESIGN This is a cross-sectional survey of children's hospitals in the US offering VAs care. We approached 142 children's hospitals that provided care for VAs via email. The survey evaluated VA clinic location, medical staffing, research participation, and treatments offered. The survey was administered between October 2021 and July 2022. RESULTS Participants from 95 eligible hospitals responded to the survey (response rate = 67%). Large areas of the Midwest and Northwest US had no available multidisciplinary VA teams or clinics. Most respondents worked at academic centers (89%), with 66% at a freestanding children's hospital, and 56% reported having a multidisciplinary clinic. Most common physician participants in clinic included hematology-oncology (91%), interventional radiology (87%), dermatology (85%), plastic surgery (81%), and otolaryngology (74%). Only 38% of programs included medical geneticists. Smaller hospitals had fewer medical and ancillary staff and offered fewer therapeutic options. Research was available at most larger institutions (69%) but less commonly at smaller hospitals (34%). CONCLUSIONS Major portions of the US lack multidisciplinary VA care. Furthermore, VA programs vary in composition and geneticists are absent from the majority of programs. These findings should inform efforts to address disparate access and develop standards of care for multidisciplinary VA care in the US.
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Affiliation(s)
- Sally Cohen-Cutler
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Julie Blatt
- Division of Pediatric Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sherry Bayliff
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Kentucky Chandler Medical Center, Lexington, KY
| | - Ionela Iacobas
- Department of Pediatrics, Texas Children's Vascular Anomalies Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adrienne Hammill
- Division of Hematology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, Cancer and Blood Diseases Institute, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Tsitsani P, Katsaras G, Soteriades ES. Barriers to and Facilitators of Providing Care for Adolescents Suffering from Rare Diseases: A Mixed Systematic Review. Pediatr Rep 2023; 15:462-482. [PMID: 37606447 PMCID: PMC10443320 DOI: 10.3390/pediatric15030043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/23/2023] Open
Abstract
Rare Diseases (RDs) in adolescents are characterized by low frequency and clinical heterogeneity, are chronic and deliberating and demand a multidisciplinary approach as well as costly and specialized treatments. Comprehending patients' and parents' needs through a mixed systematic review is essential for healthcare system planning. This mixed systematic review explored barriers to and facilitators of effective care for adolescents with RDs as perceived by patients and their parents. Three databases (2008-2023) were searched and twenty-five articles were selected and critically appraised with the Mixed Methods Appraisal Tool (MMAT; version 2018). The review followed a convergent integrated approach for data extraction according to Joanna Briggs Institute's (JBI) mixed method systematic review (MMSR) methodology. Subsequent reflexive thematic analysis categorized the barriers and facilitators into five levels (intrapersonal, interpersonal, institutional, community and public policy) following the conceptual framework of the socio-ecological model for healthcare promotion. Barriers on the institutional and public policy level stood out as the most frequently reported, resulting in unmet care needs and frustrating family dynamics. National and regional healthcare policies are rarely actually linked to pragmatic intervention programs with a measurable impact on patients' welfare. Targeted strategies involving primary care infrastructure and personnel for better coordination and management of the disease are discussed.
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Affiliation(s)
- Pelagia Tsitsani
- Healthcare Management Program, School of Economics and Management, Open University of Cyprus, 2220 Nicosia, Cyprus;
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece;
| | - Georgios Katsaras
- Paediatric Department, General Hospital of Pella—Hospital Unit of Edessa, 58200 Edessa, Greece;
| | - Elpidoforos S. Soteriades
- Healthcare Management Program, School of Economics and Management, Open University of Cyprus, 2220 Nicosia, Cyprus;
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Factors affecting pathways to care for children and adolescents with complex vascular malformations: parental perspectives. Orphanet J Rare Dis 2022; 17:271. [PMID: 35840977 PMCID: PMC9287854 DOI: 10.1186/s13023-022-02432-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022] Open
Abstract
Background Complex vascular malformations (VMs) are rare disorders that can cause pain, coagulopathy, disfigurement, asymmetric growth, and disability. Patients with complex VMs experience misdiagnosis, delayed diagnosis, delayed or inappropriate treatments, and worsened health. Given the potential consequences of delaying expert care, we must identify the factors that impede or facilitate this access to care.
Results We performed semi-structured interviews with 24 parents (21 mothers; 3 fathers; median age = 42.5 years) of children with complex VMs and overgrowth disorders living in the US, recruited through two patient advocacy groups – CLOVES Syndrome Community, and Klippel-Trenaunay Support Group. We performed thematic analysis to assess parental perspectives on barriers and facilitators to accessing expert care. We identified 11 factors, representing 6 overarching themes, affecting families’ ability to access and maintain effective care for their child: individual characteristics (clinician behaviors and characteristics, parent behaviors and characteristics), health care system (availability of specialist multidisciplinary teams, care coordination and logistics, insurance and financial issues, treatments and services), clinical characteristics (accuracy and timing of diagnosis, features of clinical presentation), social support networks, scientific progress, and luck and privilege. Additionally, access to information about VMs and VM care was a crosscutting theme affecting each of these factors. These factors influenced both the initial access to care and the ongoing maintenance of care for children with VMs. Conclusion Parents of children with VMs report multiple factors that facilitate or impede their ability to provide their child with optimal care. These factors represent possible targets for future interventions to improve care delivery for families affected by VMs. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02432-4.
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de Omena Filho RL, Petroli RJ, Soardi FC, de Paula Michelatto D, Mazzola TN, Fabbri-Scallet H, de Mello MP, Zanotti SV, Gubert IC, Monlleo I. So, and if it is not congenital adrenal hyperplasia? Addressing an undiagnosed case of genital ambiguity. Ital J Pediatr 2022; 48:89. [PMID: 35689291 PMCID: PMC9188102 DOI: 10.1186/s13052-022-01284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Congenital Adrenal Hyperplasia due to 21 hydroxylase deficiency is the most common cause of genital ambiguity in persons with XX sexual chromosomes. Genital ambiguity among persons with XY sexual chromosomes comprises diverse and rare etiologies. The deficiency of 17-beta-hydroxysteroid dehydrogenase type 3 enzyme (HSD17B3) is a rare autosomal recessive disorder due to functionally altered variants of the HSD17B3 gene. In this disorder/difference of sex development, the conversion of androstenedione into testosterone is impaired. The appearance of external genitalia of 46,XY individuals varies from typically male to almost female. Case presentation We report on a child presenting severe ambiguous genitalia. Due to access constraints, specialized care did not start until the child was 10 months old. Parents are consanguineous and were born in an area of high isonymy that is a cluster for rare recessive diseases. A new homozygous missense variant c.785G > T was found in exon 10 of the HSD17B3 gene. Conclusions Researchers-clinicians and researchers-researchers collaborative efforts to elucidate the genetic basis of this disease were critical since this etiologic investigation is not available through the public health system. This case exemplifies the families’ pilgrimage in cases of genital ambiguity due to a rare genetic condition. Recognizing the etiology was the baseline to provide information on prognosis and treatment options, and to shelter family and child doubts and hopes in order to better support their decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s13052-022-01284-9.
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Affiliation(s)
- Reinaldo Luna de Omena Filho
- Maternal, Child and Adolescent Health Center, State University of Health Sciences of Alagoas, Postgraduate Program in Health Sciences of the Institute of Biological and Health Sciences of the Federal University of Alagoas, Maceió, Brazil
| | - Reginaldo José Petroli
- Medical Genetics Sector, Faculty of Medicine, Federal University of Alagoas, Maceió, Brazil
| | - Fernanda Caroline Soardi
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | | | - Taís Nitsch Mazzola
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | - Helena Fabbri-Scallet
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | - Maricilda Palandi de Mello
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | | | | | - Isabella Monlleo
- Clinical Genetics Service, Medical Genetics Sector, Faculty of Medicine, University Hospital, Federal University of Alagoas, Avenida Lourival Melo Mota, S/N, Tabuleiro 23 do Martins, 57072-970, Maceió, Alagoas, Brasil.
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Benito-Lozano J, Arias-Merino G, Gómez-Martínez M, Ancochea-Díaz A, Aparicio-García A, Posada de la Paz M, Alonso-Ferreira V. Diagnostic Process in Rare Diseases: Determinants Associated with Diagnostic Delay. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116456. [PMID: 35682039 PMCID: PMC9180264 DOI: 10.3390/ijerph19116456] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 02/01/2023]
Abstract
Many people living with rare disease (RD) report a difficult diagnostic process from the symptom onset until they obtain the definitive diagnosis. The aim of this study was thus to ascertain the diagnostic process in RDs, and explore the determinants related with having to wait for more than one year in this process (defined as “diagnostic delay”). We conducted a case–control study, using a purpose-designed form from the Spanish Rare Diseases Patient Registry for data-collection purposes. A descriptive analysis was performed and multivariate backward logistic regression models fitted. Based on data on 1216 patients living with RDs, we identified a series of determinants associated with experiencing diagnostic delay. These included: having to travel to see a specialist other than that usually consulted in the patient’s home province (OR 2.1; 95%CI 1.6–2.9); visiting more than 10 specialists (OR 2.6; 95%CI 1.7–4.0); being diagnosed in a region other than that of the patient’s residence at the date of symptom onset (OR 2.3; 95%CI 1.5–3.6); suffering from a RD of the nervous system (OR 1.4; 95%CI 1.0–1.8). In terms of time taken to see a specialist, waiting more than 6 months to be referred from the first medical visit was the period of time which most contributed to diagnostic delay (PAR 30.2%). In conclusion, this is the first paper to use a collaborative study based on a nationwide registry to address the diagnostic process of patients living with RDs. While the evidence shows that the diagnostic process experienced by these persons is complex, more studies are needed to determine the implications that this has for their lives and those of their families at a social, educational, occupational, psychological, and financial level.
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Affiliation(s)
- Juan Benito-Lozano
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
- Universidad Nacional de Educación a Distancia (UNED), 28015 Madrid, Spain
| | - Greta Arias-Merino
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | - Mario Gómez-Martínez
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | | | - Aitor Aparicio-García
- The State Reference Center for Assistance to People Living with Rare Diseases and Their Families (CREER), Centro de Referencia Estatal de Atención a Personas con Enfermedades Raras y sus Familias, Dependiente del IMSERSO, 09001 Burgos, Spain;
| | - Manuel Posada de la Paz
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
| | - Verónica Alonso-Ferreira
- Institute of Rare Diseases Research (IIER), Instituto de Salud Carlos III, 28029 Madrid, Spain; (J.B.-L.); (G.A.-M.); (M.G.-M.); (M.P.d.l.P.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-91-822-2089
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Medicina de precisión de Enfermedades Raras. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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