How to improve a urology outpatient service? A survey of patient satisfaction

AIM: To investigate and improve our out-patients department patient satisfaction, provide minimum consultation delay and appropriate consultation duration to meet with targets. METHODS: We distributed the modified satisfaction with outpatient service (SWOPS) questionnaires developed for use in Irish hospitals by the Health Services Research between August and December 2012. The patient disclosed their age and sex and completed the modified SWOPS questionnaire anonymously. Every patient was eligible to participate in the study who attended any of the Urology Outpatient Clinics. Patients lacking capacity to consent were excluded. Additionally, each patient was only permitted to complete one questionnaire regardless of repeat attendances within the 4 mo study period. The answers to every question were presented as percentages. One-way ANOVA was used to establish whether there was a significant difference in appointment delay and “Overall Satisfaction” on the different clinic days. The unpaired t-test was applied to establish whether “Overall Satisfaction” was affected by diagnosis (benign or malignant). Paired t-test was used to establish whether “Overall Satisfaction” was affected by appointment delay and appointment length. RESULTS: Three hundred and forty-eight questionnaires were completed with an overall > 65% participation rate. Eighty-one point six percent were male and 18.4% female with a mean age of 65 ± 21 years. Mean delay time was 32 min, which 30.6% stated should be an improvement priority. The delay times for Wednesday (mean 13 min) were significantly (P < 0.05) lower than for other days (mean 36 min). Generally 12-15 min outpatient appointment length is acceptable and adequate for patients as 97.70% suggested, however 31.60% of patients would favour longer duration. Eleven point four nine percent do not want to see different doctors each time, and 31.60% of the patient feel that no change is required. Average satisfaction was 84.65%. There was no significant relationship between satisfaction and clinic day, diagnosis and consultation length, whether the patient was reviewed by a registrar or consultant. Satisfaction was universally high and independent of consultation delay/length and diagnosis. Dissatisfaction in delay times with a significant improvement on Wednesday suggests necessary and achievable improvements. Notably, the Wednesday clinic has less patients per doctor per hour and enforces a 1 patient per 15 min slot with a no over-booking policy. CONCLUSION: Surveying our patient dissatisfaction would require more frequent audits by clinicians to improve patient satisfaction and to achieve better quality of care.     

Rare association of antisynthetase syndrome and Kennedy’s disease

Antisynthetase syndrome is a type of Idiopathic Inflammatory Myopathy (IIM) associated with anti-Jo1 antibody. Kennedy's disease or X-linked spinal and bulbar muscular atrophy (SBMA) is a rare neuromuscular disease. We describe the case report of a 53-year-old man who presented with proximal muscle weakness and a history of bilateral hand tremor. Initial physical examination demonstrated "mechanic's hands", Raynaud's phenomenon, having elevated creatine kinase and lactate dehydrogenase levels and anti-Jo1 antibody positivity. His muscle biopsy demonstrated inflammatory infiltrate characteristic of IIM. Considering these findings, we reached the diagnosis of antisynthetase syndrome and commenced immunosuppressive therapy. On follow-up examination, he had developed dysphagia, and his tremor had worsened. His electroneurogram result was characteristic of Kennedy's disease, and the genetic test result showed an allele with 44 CAG repeat expansion in the androgen receptor gene of the X chromosome. This confirmed that in addition to antisynthetase syndrome, he also had Kennedy's disease. This patient now receives immunology and neurology follow-up. His symptoms have improved with low dose corticosteroids, propranolol for tremor, vitamin B supplementation, and physiotherapy. This article presents a rare case report of a patient with concurrent antisynthetase syndrome and Kennedy's disease, both of which lead to elevated creatine kinase levels and muscle weakness, thus, underpinning the importance of careful follow-up of patients with IIM and maintaining an open mind to other diagnoses when faced with refractory and/or new symptoms.     

Hyperparathyroidism simulating severe hypercalcemia syndrome

The case history of a 65 year old female patient has been reported here by the authors. The patient was admitted to the Intensive Therapy Unit owing to her repeated heart pain. Later she was transferred to the Department of Medicine to establish the exact diagnosis. Prepyloric ulcer and hypertension were occurred in her history. The symptoms of her preceding as well as her recent illness were: pain in epigastric field, nausea, adynamia, weakness, polyuria, significant loss of weight, somnolence and the shortened Q--T time in electrocardiogram related to hypercalcemia syndrome. The calcium value in blood proved to be at critically high level from time to time. The possibility of the secondary hypercalcemic state was excluded by sonographic examination and the elevated level of parathormone in blood established the diagnosis of the hyperparathyroidism. The surgical resection of parathyroidic adenoma yielded a complete recovery of the patient. The authors call the attention to the significance of the clinical signs in the diagnosis of the disease.     

Real Time SPR Assessment of the Structural Changes of Adaptive Dynamic Constitutional Frameworks as a New Route for Sensing

Cross linked gold-dynamic constitutional frameworks (DCFs) are functional materials of potential relevance for biosensing applications, given their adaptivity and high responsivity against various external stimuli (such as pH, temperature) or specific interactions with biomolecules (enzymes or DNA) via internal constitutional dynamics. However, characterization and assessment of their dynamic conformational changes in response to external stimuli has never been reported. This study proves the capability of Surface Plasmon Resonance (SPR) assays to analyse the adaptive structural modulation of a functional matrix encompassing 3D gold-dynamic constitutional frameworks (Au-DCFs) when exposed to pH variations, as external stimuli. We analyse Au-DCFs formed from Au nanoparticles, (AuNP) connected through constitutionally dynamic polymers, dynamers, with multiple functionalities. For increased generality of this proof-of-concept assay, Au-DCFs, involving DCFs designed from 1,3,5-benzene-tricarbaldehyde (BTA) connecting centres and polyethylene glycol (PEG) connectors, are covalently attached to standard SPR sensing chips (Au nanolayers, carboxyl terminated or with carboxymethyl dextran, CMD top-layer) and analysed using state-of-the art SPR instrumentation. The SPR effects of the distance from the Au-DCFs matrix to the Au nanolayer of the sensing chip, as well as of Au-DCFs thickness were investigated. This study reveals the SPR response, augmented by the AuNP, to the conformational change, i.e., shrinkage, of the dynamer and AuNP matrix when decreasing the pH, and provides an unexplored insight into the sensing applicability of SPR real-time analysis of adaptive functional materials.     

A Systematic Review of the Efficacy of Interventions to Control Aflatoxins in the Dairy Production Chain—Feed Production and Animal Feeding Interventions

The study presents a systematic review of published scientific articles investigating the effects of interventions aiming at aflatoxin reduction at the feed production and animal feeding phases of the milk value chain in order to identify the recent scientific trends and summarize the main findings available in the literature. The review strategy was designed based on the guidance of the systematic review and knowledge synthesis methodology that is applicable in the field of food safety. The Web of Science and EBSCOhost online databases were searched with predefined algorithms. After title and abstract relevance screening and relevance confirmation with full-text screening, 67 studies remained for data extraction, which were included in the review. The most important identified groups of interventions based on their mode of action and place in the technological process are as follows: low-moisture production using preservatives, acidity regulators, adsorbents and various microbiological additives. The results of the listed publications are summarized and compared for all the identified intervention groups. The paper aimed to help feed producers, farmers and relevant stakeholders to get an overview of the most suitable aflatoxin mitigation options, which is extremely important in the near future as climate change will likely be accompanied by elevated mycotoxin levels.     

Rationale,Design, and Methodological Aspects of the BUDAPEST‐GLOBAL Study (Burden of Atherosclerotic Plaques Study in Twins—Genetic Loci and the Burden of Atherosclerotic Lesions)

The heritability of coronary atherosclerotic plaque burden, coronary geometry, and phenotypes associated with increased cardiometabolic risk are largely unknown. The primary aim of the Burden of Atherosclerotic Plaques Study in Twins—Genetic Loci and the Burden of Atherosclerotic Lesions (BUDAPEST‐GLOBAL) study is to evaluate the influence of genetic and environmental factors on the burden of coronary artery disease. By design this is a prospective, single‐center, classical twin study. In total, 202 twins (61 monozygotic pairs, 40 dizygotic same‐sex pairs) were enrolled from the Hungarian Twin Registry database. All twins underwent non–contrast‐enhanced computed tomography (CT) for the detection and quantification of coronary artery calcium and for the measurement of epicardial fat volumes. In addition, a single non–contrast‐enhanced image slice was acquired at the level of L3‐L4 to assess abdominal fat distribution. Coronary CT angiography was used for the detection and quantification of plaque, stenosis, and overall coronary artery disease burden. For the primary analysis, we will assess the presence and volume of atherosclerotic plaques. Furthermore, the 3‐dimensional coronary geometry will be assessed based on the coronary CT angiography datasets. Additional phenotypic analyses will include per‐patient epicardial and abdominal fat quantity measurements. Measurements obtained from monozygotic and dizygotic twin pairs will be compared to evaluate the genetic or environmental effects of the given phenotype. The BUDAPEST‐GLOBAL study provides a unique framework to shed some light on the genetic and environmental influences of cardiometabolic disorders.     

Therapeutic effect of the latest extracorporal elimination procedure (Prometheus treatment) in acute liver failure caused by intoxication

INTRODUCTION: Despite intensive therapy the mortality of acute liver failure without organ transplantation is 60-90%. Because of organ shortage in liver transplantation, a significant number of patients dies while being on the waiting list. In order to diminish the mortality, various trials were introduced to remove the albumin-bound and water-soluble toxins in liver failure with the aim to support the spontaneous regeneration of the liver and maintaining the patients alive until liver transplantation. Prometheus treatment is a relatively new technique combining Fractionated Plasma Separation and Adsorption (FPSA) with a high-flux dialysis. During the procedure the patient's own separated albumin-rich plasma passes through special adsorbents making possible the elimination of albumin-bound toxins, while hemodialysis gets rid of water-soluble toxins. AIM: The authors' intention was to demonstrate the efficiency of Prometheus treatment in acute liver failure caused by intoxication. PATIENTS AND METHOD: Prometheus treatment was indicated in three patients who suffered from severe intoxication with paracetamol, potassium permanganate and Amanita phalloides, which resulted in a hepatic failure incurable with conservative therapy. RESULTS: Ten treatments were performed in the three female patients. No serious complication was observed. Due to the treatment the albumin-bound (indirect bilirubin p = 0.048; bile acid p = 0.001) and water-soluble (direct bilirubin p = 0.002; creatinine p = 0.007) toxins were significantly decreased. The level of ammonia, urea nitrogen, fibrinogen and antithrombin III did not change significantly. All the three patients were cured without liver transplantation. CONCLUSION: Prometheus treatment removes efficiently the accumulating toxins in acute liver failure. It is a safe elimination technique. In cases untreatable with conservative therapy it makes possible maintaining the patients alive until the liver regenerates spontaneously, or liver transplantation is feasible.