Looking for trouble? Diagnostics expanding disease and producing patients.

PubMed

Hofmann, Bjørn

2018-05-23

Novel tests give great opportunities for earlier and more precise diagnostics. At the same time, new tests expand disease, produce patients, and cause unnecessary harm in overdiagnosis and overtreatment. How can we evaluate diagnostics to obtain the benefits and avoid harm? One way is to pay close attention to the diagnostic process and its core concepts. Doing so reveals 3 errors that expand disease and increase overdiagnosis. The first error is to decouple diagnostics from harm, eg, by diagnosing insignificant conditions. The second error is to bypass proper validation of the relationship between test indicator and disease, eg, by introducing biomarkers for Alzheimer's disease before the tests are properly validated. The third error is to couple the name of disease to insignificant or indecisive indicators, eg, by lending the cancer name to preconditions, such as ductal carcinoma in situ. We need to avoid these errors to promote beneficial testing, bar harmful diagnostics, and evade unwarranted expansion of disease. Accordingly, we must stop identifying and testing for conditions that are only remotely associated with harm. We need more stringent verification of tests, and we must avoid naming indicators and indicative conditions after diseases. If not, we will end like ancient tragic heroes, succumbing because of our very best abilities. © 2018 John Wiley & Sons, Ltd.

sFlt-1/PlGF ratio test for pre-eclampsia: an economic assessment for the UK.

PubMed

Vatish, M; Strunz-McKendry, T; Hund, M; Allegranza, D; Wolf, C; Smare, C

2016-12-01

To assess the economic impact of introducing into clinical practice in the UK the soluble fms-like tyrosine kinase (sFlt-1) to placental growth factor (PlGF) ratio test for guiding the management of pre-eclampsia. We used an economic model estimating the incremental value of information, from a UK National Health Service payer's perspective, generated by the sFlt-1/PlGF ratio test, compared with current diagnostic procedures, in guiding the management of women with suspected pre-eclampsia. The economic model estimated costs associated with the diagnosis and management of pre-eclampsia in pregnant women between 24 + 0 and 36 + 6 weeks' gestation, managed in either a 'test' scenario in which the sFlt-1/PlGF test is used in addition to current diagnostic procedures, or a 'no-test' scenario in which clinical decisions are based on current diagnostic procedures alone. Test characteristics and resource use were derived from PROGNOSIS, a non-interventional study in women presenting with clinical suspicion of pre-eclampsia. The main outcome measure from the economic model was the cost per patient per episode of care, from first suspicion of pre-eclampsia to birth. Introduction of the sFlt-1/PlGF ratio test into clinical practice is expected to result in cost savings of £344 per patient compared with a no-test scenario. Savings are generated primarily through an improvement in diagnostic accuracy and subsequent reduction in unnecessary hospitalization. Introducing the sFlt-1/PlGF ratio test into clinical practice in the UK was shown to be cost-saving by reducing unnecessary hospitalization of women at low risk of developing pre-eclampsia. In addition, the test ensures that those women at higher risk are identified and managed appropriately. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. © 2016 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Utility of a point-of-care malaria rapid diagnostic test for excluding malaria as the cause of fever among HIV-positive adults in rural Rakai, Uganda.

PubMed

Mills, Lisa A; Kagaayi, Joseph; Nakigozi, Gertrude; Galiwango, Ronald M; Ouma, Joseph; Shott, Joseph P; Ssempijja, Victor; Gray, Ronald H; Wawer, Maria J; Serwadda, David; Quinn, Thomas C; Reynolds, Steven J

2010-01-01

We compared results of a malaria rapid diagnostic test (Binax Now Malaria, Binax-M, Inverness Medical Innovations, Inc., Waltham, MA) performed at rural mobile clinics in Uganda by clinicians evaluating febrile adult HIV patients to thick smear evaluated at a central laboratory by trained microscopists. Two hundred forty-six samples were analyzed, including 14 (5.7%) which were thick-smear positive for falciparum malaria. Sensitivity of Binax-M compared with thick smear was 85.7% (95% CI: 57.2-98.2), specificity 97.8% (95% CI: 94.9-99.3), positive and negative predictive values were 70.6% (95% CI: 44.0-89.7) and 99.1% (95% CI: 96.8-99.9), respectively. The rapid diagnostic test accurately ruled malaria "in or out" at the point-of-care, facilitating appropriate clinical management and averting unnecessary anti-malarial therapy.

Payer view of personalized medicine.

PubMed

Pezalla, Edmund J

2016-12-01

The process and methods used by payers when evaluating coverage of personalized medicine testing are described. Personalized medicine encompasses a number of diagnostic tools that measure drug metabolism, genetic risk for disease development, and tumor type or markers that can guide oncology treatments. However, whole genome testing, tumor marker testing, and testing for drug metabolism are additional costs to the healthcare system. In order to justify these costs, payers and health technology assessment bodies must evaluate the individual tests or groups of tests on their own merits. In order for a test to be covered by payers, test developers must demonstrate clinical utility as measured by improved outcomes or well-informed decision-making. In the United States, payers generally focus on clinical benefit to individual patients and benefits to the healthcare system. Clinical benefits include improved outcomes. Benefits to the healthcare system are generally considered to be cost offsets, which may be due to reductions in the use of unnecessary interventions or to more efficient use of resources. Provider organizations have been assuming more responsibility and liability for healthcare costs through various risk arrangements, including accountable care organizations and patient-centered medical homes. Diagnostic tests that increase efficiency, reduce unnecessary interventions, and improve outcomes will be chosen by specialists in provider organizations. For personalized medicine approaches to be adopted and covered by health plans, the methods must be shown to be analytically and clinically valid and provide clinical utility at a reasonable level of cost-effectiveness to payers. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

How to prevent overdiagnosis.

PubMed

Chiolero, Arnaud; Paccaud, Fred; Aujesky, Drahomir; Santschi, Valérie; Rodondi, Nicolas

2015-01-01

Overdiagnosis is the diagnosis of an abnormality that is not associated with a substantial health hazard and that patients have no benefit to be aware of. It is neither a misdiagnosis (diagnostic error), nor a false positive result (positive test in the absence of a real abnormality). It mainly results from screening, use of increasingly sensitive diagnostic tests, incidental findings on routine examinations, and widening diagnostic criteria to define a condition requiring an intervention. The blurring boundaries between risk and disease, physicians' fear of missing a diagnosis and patients' need for reassurance are further causes of overdiagnosis. Overdiagnosis often implies procedures to confirm or exclude the presence of the condition and is by definition associated with useless treatments and interventions, generating harm and costs without any benefit. Overdiagnosis also diverts healthcare professionals from caring about other health issues. Preventing overdiagnosis requires increasing awareness of healthcare professionals and patients about its occurrence, the avoidance of unnecessary and untargeted diagnostic tests, and the avoidance of screening without demonstrated benefits. Furthermore, accounting systematically for the harms and benefits of screening and diagnostic tests and determining risk factor thresholds based on the expected absolute risk reduction would also help prevent overdiagnosis.

A vascular laboratory protocol for improving and managing after-hours suspected acute deep venous thrombosis.

PubMed

Martin, Angela H; Eckert, George; Lemmon, Gary W; Sawchuk, Alan; Dalsing, Michael C

2014-04-01

This study reviews the clinical and workforce impact of a suggested protocol designed for the management of suspected acute deep venous thrombosis (DVT) in patients seen after standard vascular laboratory business hours. The protocol included the use of Wells score, D-dimer and a single dose of therapeutic anticoagulant to defer venous duplex ultrasound (VDU) testing until routine business hours unless contraindicated. Information was collected on medical history, physical exam and the timing of any diagnostic studies and treatment provided. Over 15% of studies done after-hours were deemed unnecessary by our protocol and in every individual the results were negative for an acute DVT. There were no adverse events from a one-time dose of anticoagulant. Limiting emergency VDU coverage to evaluate for acute DVT based on a management protocol can eliminate unnecessary after-hours VDU testing without having a negative impact on patient care.

A simple diagnostic model for ruling out pneumoconiosis among construction workers.

PubMed

Suarthana, Eva; Moons, Karel G M; Heederik, Dick; Meijer, Evert

2007-09-01

Construction workers exposed to silica-containing dust are at risk of developing silicosis even at low exposure levels. Health surveillance among these workers is commonly advised but the exact diagnostic work-up is not specified and therefore may result in unnecessary chest x ray investigations. To develop a simple diagnostic model to estimate the probability of an individual worker having pneumoconiosis from questionnaire and spirometry results, in order to accurately rule out workers without pneumoconiosis. The study was performed using cross-sectional data of 1291 Dutch natural stone and construction workers with potentially high quartz dust exposure. A multivariable logistic regression model was developed using chest x ray with ILO profusion category > or =1/1 as the reference standard. The model's calibration was evaluated with the Hosmer-Lemeshow test; the discriminative ability was determined by calculating the area under the receiver operating characteristic curve (ROC area). Internal validity of the final model was assessed by a bootstrapping procedure. For clinical application, the diagnostic model was transformed into an easy-to-use score chart. Age 40 years or older, current smoker, high-exposure job, working 15 years or longer in the construction industry, "feeling unhealthy" and FEV1 were independent predictors in the diagnostic model. The model showed good calibration (a non-significant Hosmer-Lemeshow test) and discriminative ability (ROC area 0.81, 95% CI 0.74 to 0.85). Internal validity was reasonable; the optimism corrected ROC area was 0.76. By using a cut-off point with a high negative predictive value the occupational physician can efficiently detect a large proportion of workers with a low probability of having pneumoconiosis and exclude them from unnecessary x ray investigations. This diagnostic model is an efficient and effective instrument to rule out pneumoconiosis among construction workers. Its use in health surveillance among these workers can reduce the number of redundant x ray investigations.

Are overreferrals on developmental screening tests really a problem?

PubMed

Glascoe, F P

2001-01-01

Developmental screening tests, even those meeting standards for screening test accuracy, produce numerous false-positive results for 15% to 30% of children. This is thought to produce unnecessary referrals for diagnostic testing or special services and increase the cost of screening programs. To explore whether children who pass screening tests differ in important ways from those who do not and to determine whether children overreferred for testing benefit from the scrutiny of diagnostic testing and treatment planning. Subjects were a national sample of 512 parents and their children (age range of the children, 7 months to 8 years) who participated in validation studies of various screening tests. Psychological examiners adhering to standardized directions obtained informed consent and administered at least 2 developmental screening measures (the Brigance Screens, the Battelle Developmental Inventory Screening Test, the Denver-II, and the Parents' Evaluations of Developmental Status) and a concurrent battery of diagnostic measures, including tests of intelligence, language, and academic achievement (for children aged 2(1/2) years and older). The performance on diagnostic measures of children who failed screening but were not found to have a disability (false positives) was compared with that of children who passed screening and did not have a disability on diagnostic testing (true negatives). Children with false-positive scores performed significantly (P<.001) lower on diagnostic measures than did children with true-negative scores. The false-positive group had scores in adaptive behavior, language, intelligence, and academic achievement that were 9 to 14 points lower than the scores of those in the true-negative group. When viewing the likelihood of scoring below the 25th percentile on diagnostic measures, children with false-positive scores had a relative risk of 2.6 in adaptive behavior (95% confidence interval [CI], 1.67-4.21), 3.1 in language skills (95% CI, 1.90-5.20), 6.7 on intelligence tests (95% CI, 3.28-13.50), and 4.9 on academic measures (95% CI, 2.61-9.28). Overall, 151 (70%) of the children with false-positive results scored below the 25th percentile on 1 or more diagnostic measures (the point at which most children have difficulty benefiting from typical classroom instruction) in contrast with 64 (29%) of the children with true-negative scores (odds ratio, 5.6; 95% CI, 3.73-8.49). Children with false-positive scores were also more likely to be nonwhite and to have parents who had not graduated from high school. Performance differences between children with true-negative scores and children with false-positive scores continued to be significant (P<.001) even after adjusting for sociodemographic differences between groups. Children overreferred for diagnostic testing by developmental screens perform substantially lower than children with true-negative scores on measures of intelligence, language, and academic achievement-the 3 best predictors of school success. These children also carry more psychosocial risk factors, such as limited parental education and minority status. Thus, children with false-positive screening results are an at-risk group for whom diagnostic testing may not be an unnecessary expense but rather a beneficial and needed service that can help focus intervention efforts. Although such testing will not indicate a need for special education placement, it can be useful in identifying children's needs for other programs known to improve language, cognitive, and academic skills, such as Head Start, Title I services, tutoring, private speech-language therapy, and quality day care.

Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis.

PubMed

Pfaller, Michael A; Castanheira, Mariana

2016-01-01

Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis. © The Author 2015. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape

PubMed Central

Robinson, Matthew L.; Manabe, Yukari C.

2017-01-01

Diagnosing the cause of acute febrile illness in resource-limited settings is important—to give the correct antimicrobials to patients who need them, to prevent unnecessary antimicrobial use, to detect emerging infectious diseases early, and to guide vaccine deployment. A variety of approaches are yielding more rapid and accurate tests that can detect more pathogens in a wider variety of settings. After decades of slow progress in diagnostics for acute febrile illness in resource-limited settings, a wave of converging advancements will enable clinicians in resource-limited settings to reduce uncertainty for the diagnosis of acute febrile illness. PMID:28719277

Lyssaviruses: special emphasis on rabies virus and other members of the lyssavirus genus.

PubMed

Harkess, Graeme; Fooks, Anthony R

2011-01-01

Rabies is routinely diagnosed based on the clinical description and history of exposure in a rabies-endemic country. A negative diagnostic test for rabies virus or a related lyssavirus does not exclude the clinical diagnosis. Diagnostic tests are never optimal and are entirely dependent on the nature and quality of the sample supplied. Often, only a sample from a single time point is investigated reducing the overall sensitivity of any diagnosis. With the advent of molecular biology, tests have been developed that are rapid, robust, and sensitive in support of the rapid detection and strain identification of rabies virus from clinical specimens. These molecular tests complement conventional tests in rabies diagnosis, particularly for human cases, for which an early laboratory diagnosis is critical and may decrease the number of unnecessary contacts with the patient, reduce the requirement for invasive and costly interventions, and enable the appropriate medical treatment regimen to be administered for the patient. The barrier to success is in transferring the technology for the latest techniques in rabies diagnosis to rabies-endemic countries. These barriers are not insurmountable and in liaison with international organisations, especially OIE, FAO, and WHO, these diagnostic tests will be validated for rabies diagnosis and surveillance, and implemented in modern and well-equipped diagnostic laboratories throughout the world.

Diagnostic accuracy of fine-needle aspiration cytology of thyroid gland lesions: A study of 200 cases in Himalayan belt.

PubMed

Sharma, Reetika; Verma, Neelam; Kaushal, Vijay; Sharma, Dev Raj; Sharma, Dhruv

2017-01-01

The study is undertaken to correlate the fine-needle aspiration cytology (FNAC) findings with histopathology in a spectrum of thyroid lesions and to find the diagnostic accuracy of fine-needle aspiration (FNA) so that unnecessary thyroidectomies can be avoided in benign lesions. This study was carried out over the period of 1-year (May 1, 2012-April, 30 2013). FNA specimens obtained from 200 patients were analyzed. Of these, only 40 patients underwent surgery and their thyroid specimens were subjected to histopathological examination. The age of the patients ranged from 9 to 82 years with mean age being 43 years. There was female preponderance, with male to female ratio being 1:7. On cytology out of 200 cases, 148 (74%) were benign, 25 (12.5%) were malignant, 16 (8%) were indeterminate, and 11 (5.5%) were nondiagnostic. Only 40 patients underwent surgery. On histopathology, 21 (52.5%) cases were benign and 19 (47.5%) were malignant. The statistical analysis of cytohistological correlation for both benign and malignant lesions revealed sensitivity, specificity, and diagnostic accuracy of 84%, 100% and 90%, respectively. FNAC is a minimally invasive, highly accurate and cost-effective procedure for the assessment of patients with thyroid lesions and has high -sensitivity and specificity. It acts as a good screening test and avoids unnecessary thyroidectomies.

Comparing the economic and health benefits of different approaches to diagnosing Clostridium difficile infection.

PubMed

Bartsch, Sarah M; Umscheid, Craig A; Nachamkin, Irving; Hamilton, Keith; Lee, Bruce Y

2015-01-01

Accurate diagnosis of Clostridium difficile infection (CDI) is essential to effectively managing patients and preventing transmission. Despite the availability of several diagnostic tests, the optimal strategy is debatable and their economic values are unknown. We modified our previously existing C. difficile simulation model to determine the economic value of different CDI diagnostic approaches from the hospital perspective. We evaluated four diagnostic methods for a patient suspected of having CDI: 1) toxin A/B enzyme immunoassay, 2) glutamate dehydrogenase (GDH) antigen/toxin AB combined in one test, 3) nucleic acid amplification test (NAAT), and 4) GDH antigen/toxin AB combination test with NAAT confirmation of indeterminate results. Sensitivity analysis varied the proportion of those tested with clinically significant diarrhoea, the probability of CDI, NAAT cost and CDI treatment delay resulting from a false-negative test, length of stay and diagnostic sensitivity and specificity. The GDH/toxin AB plus NAAT approach leads to the timeliest treatment with the fewest unnecessary treatments given, resulted in the best bed management and generated the lowest cost. The NAAT-alone approach also leads to timely treatment. The GDH/toxin AB diagnostic (without NAAT confirmation) approach resulted in a large number of delayed treatments, but results in the fewest secondary colonisations. Results were robust to the sensitivity analysis. Choosing the right diagnostic approach is a matter of cost and test accuracy. GDH/toxin AB plus NAAT diagnosis led to the timeliest treatment and was the least costly. Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Aerophagia due to abdomino-phrenic dyssynergia in a 2-year-old child.

PubMed

Ercoli, Pablo; García, Belinda; Del Campo, Enrique; Pinillos, Sergio

2018-05-01

We report the case of a previously healthy 2-year-old child who presented with significant abdominal distension. After several interventions that proved ineffective, pathologic aerophagia was eventually diagnosed. In pediatrics, pathologic aerophagia is an uncommon disorder that almost exclusively affects children with an underlying neurological condition. It may lead to multiple diagnostic tests and unnecessary aggressive therapies. A recent case report associated aerophagia with a novel concept of abdomino-phrenic dyssynergia.

Value of percutaneous needle biopsy of small renal tumors in patients referred for cryoablation.

PubMed

Iguchi, Toshihiro; Hiraki, Takao; Gobara, Hideo; Fujiwara, Hiroyasu; Sakurai, Jun; Matsui, Yusuke; Araki, Motoo; Nasu, Yasutomo; Kanazawa, Susumu

2017-04-01

To retrospectively evaluate the safety and diagnostic yield of needle biopsy of small renal tumors, and the clinical consequences of performing needle biopsy in patients referred for percutaneous cryoablation before their treatment. Biopsy was performed for 120 tumors (mean diameter, 2.2 cm) in 119 patients. All procedures were divided into diagnostic and non-diagnostic biopsies. Various variables were compared between the two groups. All cryoablation procedures were divided into two groups: procedures with or without simultaneous biopsy. The rates of benign or non-diagnostic tumors in each group were compared. After performing 120 initial and eight repeat biopsies, Grade 1 bleedings occurred in 44 cases. Six tumors were non-diagnostic and 114 were pathologically diagnosed. There were no significant variables between the diagnostic and non-diagnostic biopsies. Unnecessary cryoablation was avoided in nine benign lesions by performing biopsy in advance. Cryoablation performed simultaneously with biopsy included significantly more benign or non-diagnostic tumors than cryoablation performed after biopsy (15.2% vs. 1.4%; p = .01). Percutaneous biopsy of small renal tumors referred for cryoablation was a safe procedure with high diagnostic yield. The confirmation of pathological diagnosis prior to cryoablation is necessary because patients with benign tumors can avoid unnecessary treatment.

[Development of a diagnostic test system for early non-invasive detection of prostate cancer based on PCA3 mRNA levels in urine sediment using quantitative reverse tanscription polymerase chain reaction (qRT-PCR)].

PubMed

Pavlov, K A; Shkoporov, A N; Khokhlova, E V; Korchagina, A A; Sidorenkov, A V; Grigor'ev, M É; Pushkar', D Iu; Chekhonin, V P

2013-01-01

The wide introduction of prostatic specific antigen (PSA) determination into clinical practice has resulted in a larger number of prostate biopsies, while the lower age threshold for PSA has led to a larger number of unnecessary prostate biopsies. Hence, there is a need for new biomarkers that can detect prostate cancer. PCA3 is a noncoding messenger ribonucleic acid (mRNA) that is expressed exclusively in prostate cells. The aim of the study has been to develop a diagnostic test system for early non-invasive detection of prostate cancer based on PCA3 mRNA levels in urine sediment using quantitative reverse transcription polymerase chain reaction (qRT-PCR). As part of the study, a laboratory diagnostic test system prototype has been designed, an application methodology has been developed and specificity and sensitivity data of the method has been assessed. The diagnostic system has demonstrated its ability to detect significantly elevated levels of PCA 3/KLK 3 in samples from prostate cancer (PCa) patients compared with those from healthy men. The findings have shown relatively high diagnostic sensitivity, specificity and negative-predictive values for an early non-invasive screening of prostate cancer

Diagnostics for invasive Salmonella infections: current challenges and future directions

PubMed Central

Andrews, Jason R.; Ryan, Edward T.

2015-01-01

Invasive Salmonellosis caused by Salmonella enterica serotype Typhi or Paratyphi A, B, C, or invasive non-typhoidal Salmonella serotypes, is an immensely important disease cluster for which reliable, rapid diagnostic tests are not available. Blood culture remains the gold standard but is insensitive, slow, and resource-intensive. Existing molecular diagnostics have poor sensitivity due to the low organism burden in bodily fluids. Commercially available serologic tests for typhoidal Salmonella have had limited sensitivity and specificity. In high burden, resource-limited settings, reliance on clinical diagnosis or inaccurate tests often results in frequent, unnecessary treatment, which contributes selective pressure for the emergence of antimicrobial resistance. This practice also results in inadequate therapy for other etiologies of acute febrile illnesses, including leptospirosis and rickettsial infections. A number of novel serologic, molecular, transcriptomic and metabolomic approaches to diagnostics are under development. Target product profiles that outline specific needs may focus development and investment, and establish benchmarks for accuracy, cost, speed, and portability of new diagnostics. Of note, a critical barrier to diagnostic assay rollout will be the low cost and low perceived harm of empiric therapy on behalf of providers and patients, which leaves few perceived incentives to utilize diagnostics. Approaches that align incentives with societal goals of limiting inappropriate antimicrobial use, such as subsidizing diagnostics, may be essential for stimulating development and uptake of such assays in resource-limited settings. New diagnostics for invasive Salmonellosis should be developed and deployed alongside diagnostics for alternative etiologies of acute febrile illnesses to improve targeted use of antibiotics. PMID:25937611

Diagnostics for invasive Salmonella infections: Current challenges and future directions.

PubMed

Andrews, Jason R; Ryan, Edward T

2015-06-19

Invasive Salmonellosis caused by Salmonella enterica serotype Typhi or Paratyphi A, B, C, or invasive non-typhoidal Salmonella serotypes, is an immensely important disease cluster for which reliable, rapid diagnostic tests are not available. Blood culture remains the gold standard but is insensitive, slow, and resource-intensive. Existing molecular diagnostics have poor sensitivity due to the low organism burden in bodily fluids. Commercially available serologic tests for typhoidal Salmonella have had limited sensitivity and specificity. In high burden, resource-limited settings, reliance on clinical diagnosis or inaccurate tests often results in frequent, unnecessary treatment, which contributes selective pressure for the emergence of antimicrobial resistance. This practice also results in inadequate therapy for other etiologies of acute febrile illnesses, including leptospirosis and rickettsial infections. A number of novel serologic, molecular, transcriptomic and metabolomic approaches to diagnostics are under development. Target product profiles that outline specific needs may focus development and investment, and establish benchmarks for accuracy, cost, speed, and portability of new diagnostics. Of note, a critical barrier to diagnostic assay rollout will be the low cost and low perceived harm of empiric therapy on behalf of providers and patients, which leaves few perceived incentives to utilize diagnostics. Approaches that align incentives with societal goals of limiting inappropriate antimicrobial use, such as subsidizing diagnostics, may be essential for stimulating development and uptake of such assays in resource-limited settings. New diagnostics for invasive Salmonellosis should be developed and deployed alongside diagnostics for alternative etiologies of acute febrile illnesses to improve targeted use of antibiotics. Copyright © 2015. Published by Elsevier Ltd.

A Predictive Model to Estimate Cost Savings of a Novel Diagnostic Blood Panel for Diagnosis of Diarrhea-predominant Irritable Bowel Syndrome.

PubMed

Pimentel, Mark; Purdy, Chris; Magar, Raf; Rezaie, Ali

2016-07-01

A high incidence of irritable bowel syndrome (IBS) is associated with significant medical costs. Diarrhea-predominant IBS (IBS-D) is diagnosed on the basis of clinical presentation and diagnostic test results and procedures that exclude other conditions. This study was conducted to estimate the potential cost savings of a novel IBS diagnostic blood panel that tests for the presence of antibodies to cytolethal distending toxin B and anti-vinculin associated with IBS-D. A cost-minimization (CM) decision tree model was used to compare the costs of a novel IBS diagnostic blood panel pathway versus an exclusionary diagnostic pathway (ie, standard of care). The probability that patients proceed to treatment was modeled as a function of sensitivity, specificity, and likelihood ratios of the individual biomarker tests. One-way sensitivity analyses were performed for key variables, and a break-even analysis was performed for the pretest probability of IBS-D. Budget impact analysis of the CM model was extrapolated to a health plan with 1 million covered lives. The CM model (base-case) predicted $509 cost savings for the novel IBS diagnostic blood panel versus the exclusionary diagnostic pathway because of the avoidance of downstream testing (eg, colonoscopy, computed tomography scans). Sensitivity analysis indicated that an increase in both positive likelihood ratios modestly increased cost savings. Break-even analysis estimated that the pretest probability of disease would be 0.451 to attain cost neutrality. The budget impact analysis predicted a cost savings of $3,634,006 ($0.30 per member per month). The novel IBS diagnostic blood panel may yield significant cost savings by allowing patients to proceed to treatment earlier, thereby avoiding unnecessary testing. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Round pneumonia in an adult.

PubMed

Zhang, Yi; Yu, Yong-Sheng; Tang, Zheng-Hao; Chen, Xiao-Hua; Zang, Guo-Qing

2014-01-01

Round pneumonia is an uncommon form of pulmonary infection usually found in children. It may resemble pulmonary neoplasm on radiographs. We present a case of round pneumonia in a 43-year-old male with a history of smoking and a family history of lung cancer. The patient was treated with antibiotics for more than two weeks, after which the infection resolved completely both clinically and radiologically. Clinicians should consider this uncommon type of pneumonia in the differential diagnosis of spherical pulmonary masses to avoid unnecessary diagnostic tests.

More than just T₄: diagnostic testing for hyperthyroidism in cats.

PubMed

Peterson, Mark E

2013-09-01

In older cats presenting with clinical features of hyperthyroidism, confirmation of a diagnosis of thyroid disease is usually straightforward. However, the potential for false-negative and false-positive results exists with all thyroid function tests (especially in the context of routine screening of asymptomatic cats) and leads to clinical dilemmas. For example, a high serum T₄ value may be found in a cat that lacks clinical signs of hyperthyroidism, or hyperthyroidism may be suspected in a cat with normal total T₄ concentrations. To avoid unnecessary treatment and potentially adverse effects in a euthyroid cat, thyroid function tests must always be interpreted in the light of the cat's history, clinical signs, physical examination findings and other laboratory findings. In this article the author reviews the use of commonly recommended thyroid function tests, focusing on clinical scenarios that present diagnostic difficulties. In doing so, he draws on the veterinary and comparative literature, his own clinical experience, and data, unpublished to date, obtained from a series of 100 hyperthyroid cats consecutively diagnosed at his clinic.

Use of objective testing in the diagnosis of work-related asthma by physician specialty.

PubMed

Curwick, Christy C; Bonauto, David K; Adams, Darrin A

2006-10-01

Although early and accurate diagnosis of work-related asthma is critical to avoid unnecessary medical, legal, social, and economic consequences, little is currently known about the diagnostic practices of physicians treating workers with work-related asthma. To characterize the use of objective diagnostic testing for work-related asthma by physician specialty. A cross-sectional, descriptive, comparative evaluation was conducted of 301 workers' compensation claimants with work-related asthma. A few claimants (36.9%) were treated by specialists in work-related asthma (allergists, pulmonologists, or occupational medicine physicians) either initially or through the course of their claim. Workers with occupational asthma were more likely to have seen a specialist than those with work-aggravated asthma (47.9% vs 23.0%; P < .001). Less than half of the claimants with work-related asthma (43.2%) had received an objective evaluation of pulmonary function, through either pulmonary function testing or testing for reversible airflow limitation, for the evaluation of their work-related asthma. Claimants treated by specialists were significantly more likely to have received diagnostic testing during evaluation of their disease than those treated solely by generalists (82.9% vs 20.0%; P < .001). The results of this study point to the lack of appropriate diagnostic care received by workers with work-related asthma. Physicians who may have questions about diagnostic procedures should consider referral to a specialist. The development of referral networks for work-related asthma may be warranted and should be explored.

Clinical overlap between malaria and pneumonia: can malaria rapid diagnostic test play a role?

PubMed

Ukwaja, Kingsley Nnanna; Aina, Olufemi B; Talabi, Ademola A

2011-03-21

Malaria and pneumonia account for 40% of mortality among children under five years of age in sub-Saharan Africa. Due to lack of diagnostic facilities, their management is based on the integrated management of childhood illnesses (IMCI) strategy. Symptoms of malaria and pneumonia overlap in African children, necessitating dual IMCI classifications at health centres and treatment with both antibiotics and antimalarials. This study determined the prevalence of malaria-pneumonia symptom overlap and confirmed the diagnosis of malaria in these cases using a rapid diagnostic test. Consecutive consultations of 1,216 children (two months to five years old) were documented over a three-month period in a comprehensive health centre. Malaria rapid diagnostic tests were conducted only for children who had symptom overlap. Of the 1,216 children enrolled, 1,090 (90%) reported cough or fever. Among the children fulfilling the malaria case definition, 284 (30%) also met the pneumonia case definition. Twenty-three percent (284) of all children enrolled met the criteria for both malaria and pneumonia. However, only 130 (46%) of them had a positive result for malaria using a malaria rapid diagnostic test. During a malaria-pneumonia overlap, female children (chi-square 5.9, P = 0.01) and children ≥ one year (chi-square 4.8, P = 0.003) were more likely to seek care within two days of fever. Dual treatment with antimalarials and antibiotics in children with malaria-pneumonia overlap may result in unnecessary over-prescription of antimalarial medications. Use of rapid diagnostic tests in their management can potentially avoid over-prescribing of malaria medications.

Uncomplicated malaria in children: The place of rapid diagnostic test.

PubMed

Elechi, Hassan Abdullahi; Rabasa, Adamu Ibrahim; Bashir, Muhammad Faruk; Gofama, Mustapha Modu; Ibrahim, Halima Abubakar; Askira, Umoru Muhammed

2015-01-01

Malaria has remained a major cause of morbidity and mortality among the under-five children in Nigeria. Prompt and accurate diagnosis of malaria is necessary in controlling this high burden and preventing unnecessary use of anti-malarial drugs. Malaria rapid diagnostic test (MRDT) offers the hope of achieving this goal. However, the performance of these kits among the most vulnerable age group to malaria is inadequate. In this cross-sectional study, 433 out-patients, aged <5 years with fever or history of fever were enrolled. Each candidate was tested for malaria parasitaemia using ACON; malaria pf. Thick and thin films were also prepared from the same finger prick blood for each candidate. Malaria rapid diagnostic test had sensitivity of 8.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 74%. The sensitivity of MRDT increased with increasing age. This effect of age on sensitivity was statistically significant (P = 0.007). Similarly parasite density had significant effect on the sensitivity of MRDT (P = <0.001). Histidine-rich protein-2 based MRDT is not a reliable mean of diagnosing malaria in the under-five age children with acute uncomplicated malaria.

Challenges for allergy diagnosis in regions with complex pollen exposures.

PubMed

Barber, Domingo; Díaz-Perales, Araceli; Villalba, Mayte; Chivato, Tomas

2015-02-01

Over the past few decades, significant scientific progress has influenced clinical allergy practice. The biological standardization of extracts was followed by the massive identification and characterization of new allergens and their progressive use as diagnostic tools including allergen micro arrays that facilitate the simultaneous testing of more than 100 allergen components. Specific diagnosis is the basis of allergy practice and is always aiming to select the best therapeutic or avoidance intervention. As a consequence, redundant or irrelevant information might be adding unnecessary cost and complexity to daily clinical practice. A rational use of the different diagnostic alternatives would allow a significant improvement in the diagnosis and treatment of allergic patients, especially for those residing in complex pollen exposure areas.

A dynamic integrated fault diagnosis method for power transformers.

PubMed

Gao, Wensheng; Bai, Cuifen; Liu, Tong

2015-01-01

In order to diagnose transformer fault efficiently and accurately, a dynamic integrated fault diagnosis method based on Bayesian network is proposed in this paper. First, an integrated fault diagnosis model is established based on the causal relationship among abnormal working conditions, failure modes, and failure symptoms of transformers, aimed at obtaining the most possible failure mode. And then considering the evidence input into the diagnosis model is gradually acquired and the fault diagnosis process in reality is multistep, a dynamic fault diagnosis mechanism is proposed based on the integrated fault diagnosis model. Different from the existing one-step diagnosis mechanism, it includes a multistep evidence-selection process, which gives the most effective diagnostic test to be performed in next step. Therefore, it can reduce unnecessary diagnostic tests and improve the accuracy and efficiency of diagnosis. Finally, the dynamic integrated fault diagnosis method is applied to actual cases, and the validity of this method is verified.

A Dynamic Integrated Fault Diagnosis Method for Power Transformers

PubMed Central

Gao, Wensheng; Liu, Tong

2015-01-01

In order to diagnose transformer fault efficiently and accurately, a dynamic integrated fault diagnosis method based on Bayesian network is proposed in this paper. First, an integrated fault diagnosis model is established based on the causal relationship among abnormal working conditions, failure modes, and failure symptoms of transformers, aimed at obtaining the most possible failure mode. And then considering the evidence input into the diagnosis model is gradually acquired and the fault diagnosis process in reality is multistep, a dynamic fault diagnosis mechanism is proposed based on the integrated fault diagnosis model. Different from the existing one-step diagnosis mechanism, it includes a multistep evidence-selection process, which gives the most effective diagnostic test to be performed in next step. Therefore, it can reduce unnecessary diagnostic tests and improve the accuracy and efficiency of diagnosis. Finally, the dynamic integrated fault diagnosis method is applied to actual cases, and the validity of this method is verified. PMID:25685841

Utility of component diagnostic testing in guiding oral food challenges to milk and egg.

PubMed

Wang, Julie

2016-11-01

Food allergies affect up to 8% of children, and milk and egg allergies are the most common triggers. Accurately diagnosing these food allergies is important to prevent allergic reactions and to avoid unnecessary dietary restrictions. However, positive skin-prick tests and detectable levels of serum food specific immunoglobulin E (IgE) alone may not be diagnostic for food allergy. Advances in the identification of relevant allergens and the development of recombinant proteins now allow assessment of IgE binding to individual proteins within a food. Component-resolved diagnostics (CRD) have the potential to provide more accurate assessments of clinical reactivity to food allergens. To examine the available data for CRD for milk and egg allergies. This review discussed studies that evaluated the utility of CRD for guiding decisions about food challenges for milk and egg. Results of studies indicated that CRD may offer increased specificity, but sensitivity was lacking when compared with standard skin-prick testing and measurement of serum food specific IgE levels. The role of CRD in the diagnosis and management of milk and egg allergies is not well established at this time. Further studies are needed to explore the diagnostic value of CRD for milk and egg allergies.

Use and limitations of malaria rapid diagnostic testing by community health workers in war-torn Democratic Republic of Congo.

PubMed

Hawkes, Michael; Katsuva, Jean Paul; Masumbuko, Claude K

2009-12-23

Accurate and practical malaria diagnostics, such as immunochromatographic rapid diagnostic tests (RDTs), have the potential to avert unnecessary treatments and save lives. Volunteer community health workers (CHWs) represent a potentially valuable human resource for expanding this technology to where it is most needed, remote rural communities in sub-Saharan Africa with limited health facilities and personnel. This study reports on a training programme for CHWs to incorporate RDTs into their management strategy for febrile children in the Democratic Republic of Congo, a tropical African setting ravaged by human conflict. Prospective cohort study, satisfaction questionnaire and decision analysis. Twelve CHWs were trained to safely and accurately perform and interpret RDTs, then successfully implemented rapid diagnostic testing in their remote community in a cohort of 357 febrile children. CHWs were uniformly positive in evaluating RDTs for their utility and ease of use. However, high malaria prevalence in this cohort (93% by RDTs, 88% by light microscopy) limited the cost-effectiveness of RDTs compared to presumptive treatment of all febrile children, as evidenced by findings from a simplified decision analysis. CHWs can safely and effectively use RDTs in their management of febrile children; however, cost-effectiveness of RDTs is limited in zones of high malaria prevalence.

Use and limitations of malaria rapid diagnostic testing by community health workers in war-torn Democratic Republic of Congo

PubMed Central

2009-01-01

Background Accurate and practical malaria diagnostics, such as immunochromatographic rapid diagnostic tests (RDTs), have the potential to avert unnecessary treatments and save lives. Volunteer community health workers (CHWs) represent a potentially valuable human resource for expanding this technology to where it is most needed, remote rural communities in sub-Saharan Africa with limited health facilities and personnel. This study reports on a training programme for CHWs to incorporate RDTs into their management strategy for febrile children in the Democratic Republic of Congo, a tropical African setting ravaged by human conflict. Methods Prospective cohort study, satisfaction questionnaire and decision analysis. Results Twelve CHWs were trained to safely and accurately perform and interpret RDTs, then successfully implemented rapid diagnostic testing in their remote community in a cohort of 357 febrile children. CHWs were uniformly positive in evaluating RDTs for their utility and ease of use. However, high malaria prevalence in this cohort (93% by RDTs, 88% by light microscopy) limited the cost-effectiveness of RDTs compared to presumptive treatment of all febrile children, as evidenced by findings from a simplified decision analysis. Conclusions CHWs can safely and effectively use RDTs in their management of febrile children; however, cost-effectiveness of RDTs is limited in zones of high malaria prevalence. PMID:20028563

[Infantile Munchausen syndrome. Etiology, diagnostic criteria, and treatment].

PubMed

Morales-Franco, B; de la Morena-Fernández, M L

1995-01-01

In this paper, we study a special kind of child abuse, the Münchhausen Syndrome by proxy, which consists of a group of diseases that some parents invent in their own children. These parents describe false symptoms of disease in their children, or manipulate the bodies of their children in order to cause alterations. Their purpose is that the doctor will carry out diagnostic tests and medical treatments with the children who really aren't ill. Our objective is to understand this syndrome, so we can report the factors that influence its appearance, study the diagnostic guidelines and the importance of doing a correct differential diagnostic with other real pathologies, and we analyze the preventive and therapeutic measures that health professionals must carry out in children and in their parents. When these professionals understand this syndrome they will be able to detect it before children are subjected to more unnecessary suffering. And, they will be able to prevent that these aggressions on children continue.

Age-Specific Cutoff Value for the Application of Percent Free Prostate-Specific Antigen (PSA) in Chinese Men with Serum PSA Levels of 4.0-10.0 ng/ml.

PubMed

Chen, Rui; Huang, Yiran; Cai, Xiaobing; Xie, Liping; He, Dalin; Zhou, Liqun; Xu, Chuanliang; Gao, Xu; Ren, Shancheng; Wang, Fubo; Ma, Lulin; Wei, Qiang; Yin, Changjun; Tian, Ye; Sun, Zhongquan; Fu, Qiang; Ding, Qiang; Zheng, Junhua; Ye, Zhangqun; Ye, Dingwei; Xu, Danfeng; Hou, Jianquan; Xu, Kexin; Yuan, Jianlin; Gao, Xin; Liu, Chunxiao; Pan, Tiejun; Sun, Yinghao

2015-01-01

The influence of age on the performance of percent free prostate-specific antigen (%fPSA) in diagnosing prostate cancer (PCa) in East Asians is controversial. We tested the diagnostic performance of %fPSA in a multi-center biopsy cohort in China and identified the proper age-specific cutoff values to avoid unnecessary biopsies. Consecutive patients with a prostate-specific antigen (PSA) level of 4.0-10.0 ng/ml or 10.1-20.0 ng/ml who underwent transrectal ultrasound-guided or transperineal prostate biopsy were enrolled from 22 Chinese medical centers from Jan 1, 2010 to Dec 31, 2013. The diagnostic accuracy of PSA and %fPSA was determined using the area under the receiver operating characteristic (ROC) curve (AUC). Age-specific cutoff values were calculated using ROC curve analysis. The median %fPSA was much lower in younger patients compared with older patients with a PSA level of 4.0-10.0 ng/ml or 10.1-20.0 ng/ml. The AUC of %fPSA was higher than PSA only in older patients. In patients aged 50 to 59 years, %fPSA failed to improve the diagnosis compared with PSA in these two PSA ranges. Age-specific cutoff values were 24%, 27% and 32% for patients aged 60-69, 70-79 and ≥80 years, respectively, to reduce unnecessary biopsies in men with PSA levels of 4.0-10.0 ng/ml to detect 90% of all PCa. The effectiveness of %fPSA is correlated with age in the Chinese population. Age-specific cutoff values would help avoid unnecessary biopsies in the Chinese population.

Age-Specific Cutoff Value for the Application of Percent Free Prostate-Specific Antigen (PSA) in Chinese Men with Serum PSA Levels of 4.0–10.0 ng/ml

PubMed Central

Xie, Liping; He, Dalin; Zhou, Liqun; Xu, Chuanliang; Gao, Xu; Ren, Shancheng; Wang, Fubo; Ma, Lulin; Wei, Qiang; Yin, Changjun; Tian, Ye; Sun, Zhongquan; Fu, Qiang; Ding, Qiang; Zheng, Junhua; Ye, Zhangqun; Ye, Dingwei; Xu, Danfeng; Hou, Jianquan; Xu, Kexin; Yuan, Jianlin; Gao, Xin; Liu, Chunxiao; Pan, Tiejun; Sun, Yinghao

2015-01-01

Objective The influence of age on the performance of percent free prostate-specific antigen (%fPSA) in diagnosing prostate cancer (PCa) in East Asians is controversial. We tested the diagnostic performance of %fPSA in a multi-center biopsy cohort in China and identified the proper age-specific cutoff values to avoid unnecessary biopsies. Methods Consecutive patients with a prostate-specific antigen (PSA) level of 4.0–10.0 ng/ml or 10.1–20.0 ng/ml who underwent transrectal ultrasound-guided or transperineal prostate biopsy were enrolled from 22 Chinese medical centers from Jan 1, 2010 to Dec 31, 2013. The diagnostic accuracy of PSA and %fPSA was determined using the area under the receiver operating characteristic (ROC) curve (AUC). Age-specific cutoff values were calculated using ROC curve analysis. Results The median %fPSA was much lower in younger patients compared with older patients with a PSA level of 4.0–10.0 ng/ml or 10.1–20.0 ng/ml. The AUC of %fPSA was higher than PSA only in older patients. In patients aged 50 to 59 years, %fPSA failed to improve the diagnosis compared with PSA in these two PSA ranges. Age-specific cutoff values were 24%, 27% and 32% for patients aged 60–69, 70–79 and ≥80 years, respectively, to reduce unnecessary biopsies in men with PSA levels of 4.0–10.0 ng/ml to detect 90% of all PCa. Conclusions The effectiveness of %fPSA is correlated with age in the Chinese population. Age-specific cutoff values would help avoid unnecessary biopsies in the Chinese population. PMID:26091007

Costs and benefits of rapid screening of methicillin-resistant Staphylococcus aureus carriage in intensive care units: a prospective multicenter study

PubMed Central

2012-01-01

Introduction Pre-emptive isolation of suspected methicillin-resistant Staphylococcus aureus (MRSA) carriers is a cornerstone of successful MRSA control policies. Implementation of such strategies is hampered when using conventional cultures with diagnostic delays of three to five days, as many non-carriers remain unnecessarily isolated. Rapid diagnostic testing (RDT) reduces the amount of unnecessary isolation days, but costs and benefits have not been accurately determined in intensive care units (ICUs). Methods Embedded in a multi-center hospital-wide study in 12 Dutch hospitals we quantified cost per isolation day avoided using RDT for MRSA, added to conventional cultures, in ICUs. BD GeneOhm™ MRSA PCR (IDI) and Xpert MRSA (GeneXpert) were subsequently used during 17 and 14 months, and their test characteristics were calculated with conventional culture results as reference. We calculated the number of pre-emptive isolation days avoided and incremental costs of adding RDT. Results A total of 163 patients at risk for MRSA carriage were screened and MRSA prevalence was 3.1% (n = 5). Duration of isolation was 27.6 and 21.4 hours with IDI and GeneXpert, respectively, and would have been 96.0 hours when based on conventional cultures. The negative predictive value was 100% for both tests. Numbers of isolation days were reduced by 44.3% with PCR-based screening at the additional costs of €327.84 (IDI) and €252.14 (GeneXpert) per patient screened. Costs per isolation day avoided were €136.04 (IDI) and €121.76 (GeneXpert). Conclusions In a low endemic setting for MRSA, RDT safely reduced the number of unnecessary isolation days on ICUs by 44%, at the costs of €121.76 to €136.04 per isolation day avoided. PMID:22314204

Controversies in the Management of Asymptomatic Patients Sustaining Penetrating Thoracoabdominal Wounds

PubMed Central

Parreira, Jose Gustavo; Rasslan, Samir; Utiyama, Edivaldo M.

2008-01-01

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them. PMID:18925332

Diagnostic reasoning by hospital pharmacists: assessment of attitudes, knowledge, and skills.

PubMed

Chernushkin, Kseniya; Loewen, Peter; de Lemos, Jane; Aulakh, Amneet; Jung, Joanne; Dahri, Karen

2012-07-01

Hospital pharmacists participate in activities that may be considered diagnostic. Two reasoning approaches to diagnosis have been described: non-analytic and analytic. Of the 6 analytic traditions, the probabilistic tradition has been shown to improve diagnostic accuracy and reduce unnecessary testing. To the authors' knowledge, pharmacists' attitudes toward having a diagnostic role and their diagnostic knowledge and skills have never been studied. To describe pharmacists' attitudes toward the role of diagnosis in pharmacotherapeutic problem-solving and to characterize the extent of pharmacists' knowledge and skills related to diagnostic literacy. Pharmacists working within Lower Mainland Pharmacy Services (British Columbia) who spent at least 33% of their time in direct patient care were invited to participate in a prospective observational survey. The survey sought information about demographic characteristics and attitudes toward diagnosis. Diagnostic knowledge and skills were tested by means of 3 case scenarios. The analysis included simple descriptive statistics and inferential statistics to evaluate relationships between responses and experience and training. Of 266 pharmacists invited to participate, 94 responded. The attitudes section of the survey was completed by 90 pharmacists; of these, 80 (89%) agreed with the definition of "diagnosis" proposed in the survey, and 83 (92%) agreed that it is important for pharmacists to have diagnosis-related skills. Respondents preferred an analytic to a non-analytic approach to diagnostic decision-making. The probabilistic tradition was not the preferred method in any of the 3 cases. In evaluating 5 clinical scenarios that might require diagnostic skills, on average 84% of respondents agreed that they should be involved in assessing such problems. Respondents' knowledge of and ability to apply probabilistic diagnostic tools were highest for test sensitivity (average of 61% of respondents with the correct answers) and lower for test specificity (average of 48% with correct answers) and likelihood ratios (average of 39% with correct answers). Respondents to this survey strongly believed that diagnostic skills were important for solving drug-related problems, but they demonstrated low levels of knowledge and ability to apply concepts of probabilistic diagnostic reasoning. Opportunities to expand pharmacists' knowledge of diagnostic reasoning exist, and the findings reported here indicate that pharmacists would consider such professional development valuable.

A WAO - ARIA - GA²LEN consensus document on molecular-based allergy diagnostics

PubMed Central

2013-01-01

Molecular-based allergy (MA) diagnostics is an approach used to map the allergen sensitization of a patient at a molecular level, using purified natural or recombinant allergenic molecules (allergen components) instead of allergen extracts. Since its introduction, MA diagnostics has increasingly entered routine care, with currently more than 130 allergenic molecules commercially available for in vitro specific IgE (sIgE) testing. MA diagnostics allows for an increased accuracy in allergy diagnosis and prognosis and plays an important role in three key aspects of allergy diagnosis: (1) resolving genuine versus cross-reactive sensitization in poly-sensitized patients, thereby improving the understanding of triggering allergens; (2) assessing, in selected cases, the risk of severe, systemic versus mild, local reactions in food allergy, thereby reducing unnecessary anxiety for the patient and the need for food challenge testing; and (3) identifying patients and triggering allergens for specific immunotherapy (SIT). Singleplex and multiplex measurement platforms are available for MA diagnostics. The Immuno-Solid phase Allergen Chip (ISAC) is the most comprehensive platform currently available, which involves a biochip technology to measure sIgE antibodies against more than one hundred allergenic molecules in a single assay. As the field of MA diagnostics advances, future work needs to focus on large-scale, population-based studies involving practical applications, elucidation and expansion of additional allergenic molecules, and support for appropriate test interpretation. With the rapidly expanding evidence-base for MA diagnosis, there is a need for allergists to keep abreast of the latest information. The aim of this consensus document is to provide a practical guide for the indications, determination, and interpretation of MA diagnostics for clinicians trained in allergology. PMID:24090398

A WAO - ARIA - GA²LEN consensus document on molecular-based allergy diagnostics.

PubMed

Canonica, Giorgio Walter; Ansotegui, Ignacio J; Pawankar, Ruby; Schmid-Grendelmeier, Peter; van Hage, Marianne; Baena-Cagnani, Carlos E; Melioli, Giovanni; Nunes, Carlos; Passalacqua, Giovanni; Rosenwasser, Lanny; Sampson, Hugh; Sastre, Joaquin; Bousquet, Jean; Zuberbier, Torsten

2013-10-03

Molecular-based allergy (MA) diagnostics is an approach used to map the allergen sensitization of a patient at a molecular level, using purified natural or recombinant allergenic molecules (allergen components) instead of allergen extracts. Since its introduction, MA diagnostics has increasingly entered routine care, with currently more than 130 allergenic molecules commercially available for in vitro specific IgE (sIgE) testing.MA diagnostics allows for an increased accuracy in allergy diagnosis and prognosis and plays an important role in three key aspects of allergy diagnosis: (1) resolving genuine versus cross-reactive sensitization in poly-sensitized patients, thereby improving the understanding of triggering allergens; (2) assessing, in selected cases, the risk of severe, systemic versus mild, local reactions in food allergy, thereby reducing unnecessary anxiety for the patient and the need for food challenge testing; and (3) identifying patients and triggering allergens for specific immunotherapy (SIT).Singleplex and multiplex measurement platforms are available for MA diagnostics. The Immuno-Solid phase Allergen Chip (ISAC) is the most comprehensive platform currently available, which involves a biochip technology to measure sIgE antibodies against more than one hundred allergenic molecules in a single assay. As the field of MA diagnostics advances, future work needs to focus on large-scale, population-based studies involving practical applications, elucidation and expansion of additional allergenic molecules, and support for appropriate test interpretation. With the rapidly expanding evidence-base for MA diagnosis, there is a need for allergists to keep abreast of the latest information. The aim of this consensus document is to provide a practical guide for the indications, determination, and interpretation of MA diagnostics for clinicians trained in allergology.

The post-pulmonary infarction syndrome.

PubMed

Sklaroff, H J

1979-12-01

Following pulmonary infarction, three patients developed the classical signs and symptoms of the Dressler syndrome associated with persistent left pleural effusion. Each responded dramatically to corticosteroid therapy. While the pathogenesis of this "Post-Pulmonary Infarction syndrome," like the Dressler syndrome, is unclear, the response to corticosteroid therapy is both dramatic and diagnostic and may spare the patient prolonged discomfort and unnecessary diagnostic procedures.

“Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention”

PubMed Central

2013-01-01

Background We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers. Methods The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011. Results Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year. Conclusions The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision. PMID:23566021

Diagnostic accuracy of two multiplex real-time polymerase chain reaction assays for the diagnosis of meningitis in children in a resource-limited setting.

PubMed

Khumalo, Jermaine; Nicol, Mark; Hardie, Diana; Muloiwa, Rudzani; Mteshana, Phindile; Bamford, Colleen

2017-01-01

Accurate etiological diagnosis of meningitis is important, but difficult in resource-limited settings due to prior administration of antibiotics and lack of viral diagnostics. We aimed to develop and validate 2 real-time multiplex PCR (RT-PCR) assays for the detection of common causes of community-acquired bacterial and viral meningitis in South African children. We developed 2 multiplex RT- PCRs for detection of S. pneumoniae, N. meningitidis, H. influenzae, enteroviruses, mumps virus and herpes simplex virus. We tested residual CSF samples from children presenting to a local paediatric hospital over a one-year period, whose CSF showed an abnormal cell count. Results were compared with routine diagnostic tests and the final discharge diagnosis. We calculated accuracy of the bacterial RT-PCR assay compared to CSF culture and using World Health Organisation definitions of laboratory-confirmed bacterial meningitis. From 292 samples, bacterial DNA was detected in 12 (4.1%) and viral nucleic acids in 94 (32%). Compared to CSF culture, the sensitivity and specificity of the bacterial RT-PCR was 100% and 97.2% with complete agreement in organism identification. None of the cases positive by viral RT-PCR had a bacterial cause confirmed on CSF culture. Only 9/90 (10%) of patients diagnosed clinically as bacterial meningitis or partially treated bacterial meningitis tested positive with the bacterial RT-PCR. In this population the use of 2 multiplex RT-PCRs targeting 6 common pathogens gave promising results. If introduced into routine diagnostic testing, these multiplex RT-PCR assays would supplement other diagnostic tests, and have the potential to limit unnecessary antibiotic therapy and hospitalisation.

Diagnostic accuracy of two multiplex real-time polymerase chain reaction assays for the diagnosis of meningitis in children in a resource-limited setting

PubMed Central

Khumalo, Jermaine; Nicol, Mark; Hardie, Diana; Muloiwa, Rudzani; Mteshana, Phindile

2017-01-01

Introduction Accurate etiological diagnosis of meningitis is important, but difficult in resource-limited settings due to prior administration of antibiotics and lack of viral diagnostics. We aimed to develop and validate 2 real-time multiplex PCR (RT-PCR) assays for the detection of common causes of community-acquired bacterial and viral meningitis in South African children. Methods We developed 2 multiplex RT- PCRs for detection of S. pneumoniae, N. meningitidis, H. influenzae, enteroviruses, mumps virus and herpes simplex virus. We tested residual CSF samples from children presenting to a local paediatric hospital over a one-year period, whose CSF showed an abnormal cell count. Results were compared with routine diagnostic tests and the final discharge diagnosis. We calculated accuracy of the bacterial RT-PCR assay compared to CSF culture and using World Health Organisation definitions of laboratory-confirmed bacterial meningitis. Results From 292 samples, bacterial DNA was detected in 12 (4.1%) and viral nucleic acids in 94 (32%). Compared to CSF culture, the sensitivity and specificity of the bacterial RT-PCR was 100% and 97.2% with complete agreement in organism identification. None of the cases positive by viral RT-PCR had a bacterial cause confirmed on CSF culture. Only 9/90 (10%) of patients diagnosed clinically as bacterial meningitis or partially treated bacterial meningitis tested positive with the bacterial RT-PCR. Discussion In this population the use of 2 multiplex RT-PCRs targeting 6 common pathogens gave promising results. If introduced into routine diagnostic testing, these multiplex RT-PCR assays would supplement other diagnostic tests, and have the potential to limit unnecessary antibiotic therapy and hospitalisation. PMID:28346504

Infectious Disease Management through Point-of-Care Personalized Medicine Molecular Diagnostic Technologies

PubMed Central

Bissonnette, Luc; Bergeron, Michel G.

2012-01-01

Infectious disease management essentially consists in identifying the microbial cause(s) of an infection, initiating if necessary antimicrobial therapy against microbes, and controlling host reactions to infection. In clinical microbiology, the turnaround time of the diagnostic cycle (>24 hours) often leads to unnecessary suffering and deaths; approaches to relieve this burden include rapid diagnostic procedures and more efficient transmission or interpretation of molecular microbiology results. Although rapid nucleic acid-based diagnostic testing has demonstrated that it can impact on the transmission of hospital-acquired infections, we believe that such life-saving procedures should be performed closer to the patient, in dedicated 24/7 laboratories of healthcare institutions, or ideally at point of care. While personalized medicine generally aims at interrogating the genomic information of a patient, drug metabolism polymorphisms, for example, to guide drug choice and dosage, personalized medicine concepts are applicable in infectious diseases for the (rapid) identification of a disease-causing microbe and determination of its antimicrobial resistance profile, to guide an appropriate antimicrobial treatment for the proper management of the patient. The implementation of point-of-care testing for infectious diseases will require acceptance by medical authorities, new technological and communication platforms, as well as reimbursement practices such that time- and life-saving procedures become available to the largest number of patients. PMID:25562799

Evaluation of SMS reminder messages for altering treatment adherence and health seeking perceptions among malaria care-seekers in Nigeria.

PubMed

Liu, Jenny X; Modrek, Sepideh

2016-12-01

In Nigeria, access to malaria diagnostics may be expanded if drug retailers were allowed to administer malaria rapid diagnostic tests (RDTs). A 2012 pilot intervention showed that short message service (SMS) reminder messages could boost treatment adherence to RDT results by 10-14% points. This study aimed to replicate the SMS intervention in a different population, and additionally test the effect of an expanded message about anticipated RDT access policy change on customers' acceptability for drug retailers' administration of RDTs. One day after being tested with an RDT, participants who purchased malaria treatment from drug shops were randomized to receive (1) a basic SMS reminder repeating the RDT result and appropriate treatment actions, (2) an expanded SMS reminder additionally saying that the 'government might allow pharmacists/chemists to do RDTs' or (3) no SMS reminders (i.e. control). Using regression analysis, we estimate intent-to-treat (ITT) and treatment effects on the treated for 686 study participants. Results corroborate previous findings that a basic SMS reminder increased treatment adherence [odds ratio (OR) = 1.53, 95% CI 0.96-2.44] and decreased use of unnecessary anti-malarials for RDT-negative adults [OR = 0.63, 95% CI 0.39-1.00]. The expanded SMS also increased adherence for adults [OR = 1.42, 95% CI 0.97-2.07], but the effects for sick children differed-the basic SMS did not have any measurable impact on treatment adherence [OR = 0.87, 95% CI 0.24-3.09] or use of unnecessary anti-malarials [OR = 1.27, 95% CI 0.32-1.93], and the expanded SMS actually led to poorer treatment adherence [OR = 0.26, 95% CI 0.10-0.66] and increased use of unnecessary anti-malarials [OR = 4.67, 95% CI 1.76-12.43]. Further, the targeted but neutral message in the expanded SMS lowered acceptance for drug retailers' administration of RDTs [OR = 0.55, 95% CI 0.10-2.93], counter to what we hypothesized. Future SMS interventions should show consistent positive results across populations and be attuned to message length and content before initiating a larger messaging campaign. © The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

Evaluation of SMS reminder messages for altering treatment adherence and health seeking perceptions among malaria care-seekers in Nigeria

PubMed Central

Liu, Jenny X.; Modrek, Sepideh

2016-01-01

In Nigeria, access to malaria diagnostics may be expanded if drug retailers were allowed to administer malaria rapid diagnostic tests (RDTs). A 2012 pilot intervention showed that short message service (SMS) reminder messages could boost treatment adherence to RDT results by 10–14% points. This study aimed to replicate the SMS intervention in a different population, and additionally test the effect of an expanded message about anticipated RDT access policy change on customers’ acceptability for drug retailers’ administration of RDTs. One day after being tested with an RDT, participants who purchased malaria treatment from drug shops were randomized to receive (1) a basic SMS reminder repeating the RDT result and appropriate treatment actions, (2) an expanded SMS reminder additionally saying that the ‘government might allow pharmacists/chemists to do RDTs’ or (3) no SMS reminders (i.e. control). Using regression analysis, we estimate intent-to-treat (ITT) and treatment effects on the treated for 686 study participants. Results corroborate previous findings that a basic SMS reminder increased treatment adherence [odds ratio (OR) = 1.53, 95% CI 0.96–2.44] and decreased use of unnecessary anti-malarials for RDT-negative adults [OR = 0.63, 95% CI 0.39–1.00]. The expanded SMS also increased adherence for adults [OR = 1.42, 95% CI 0.97–2.07], but the effects for sick children differed—the basic SMS did not have any measurable impact on treatment adherence [OR = 0.87, 95% CI 0.24–3.09] or use of unnecessary anti-malarials [OR = 1.27, 95% CI 0.32–1.93], and the expanded SMS actually led to poorer treatment adherence [OR = 0.26, 95% CI 0.10–0.66] and increased use of unnecessary anti-malarials [OR = 4.67, 95% CI 1.76–12.43]. Further, the targeted but neutral message in the expanded SMS lowered acceptance for drug retailers' administration of RDTs [OR = 0.55, 95% CI 0.10–2.93], counter to what we hypothesized. Future SMS interventions should show consistent positive results across populations and be attuned to message length and content before initiating a larger messaging campaign. PMID:27315831

Rationale and design of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary heart disease 2 trial (CE-MARC 2): A prospective, multicenter, randomized trial of diagnostic strategies in suspected coronary heart disease

PubMed Central

Ripley, David P.; Brown, Julia M.; Everett, Colin C.; Bijsterveld, Petra; Walker, Simon; Sculpher, Mark; McCann, Gerry P.; Berry, Colin; Plein, Sven; Greenwood, John P.

2015-01-01

Background A number of investigative strategies exist for the diagnosis of coronary heart disease (CHD). Despite the widespread availability of noninvasive imaging, invasive angiography is commonly used early in the diagnostic pathway. Consequently, approximately 60% of angiograms reveal no evidence of obstructive coronary disease. Reducing unnecessary angiography has potential financial savings and avoids exposing the patient to unnecessary risk. There are no large-scale comparative effectiveness trials of the different diagnostic strategies recommended in international guidelines and none that have evaluated the safety and efficacy of cardiovascular magnetic resonance. Trial Design CE-MARC 2 is a prospective, multicenter, 3-arm parallel group, randomized controlled trial of patients with suspected CHD (pretest likelihood 10%-90%) requiring further investigation. A total of 1,200 patients will be randomized on a 2:2:1 basis to receive 3.0-T cardiovascular magnetic resonance–guided care, single-photon emission computed tomography–guided care (according to American College of Cardiology/American Heart Association appropriate-use criteria), or National Institute for Health and Care Excellence guidelines–based management. The primary (efficacy) end point is the occurrence of unnecessary angiography as defined by a normal (>0.8) invasive fractional flow reserve. Safety of each strategy will be assessed by 3-year major adverse cardiovascular event rates. Cost-effectiveness and health-related quality-of-life measures will be performed. Conclusions The CE-MARC 2 trial will provide comparative efficacy and safety evidence for 3 different strategies of investigating patients with suspected CHD, with the intension of reducing unnecessary invasive angiography rates. Evaluation of these management strategies has the potential to improve patient care, health-related quality of life, and the cost-effectiveness of CHD investigation. PMID:25497243

Nonpalpable testes: Ultrasound and contralateral testicular hypertrophy predict the surgical access, avoiding unnecessary laparoscopy.

PubMed

Berger, Christoph; Haid, Bernhard; Becker, Tanja; Koen, Mark; Roesch, Judith; Oswald, Josef

2018-04-01

In up to 20% of patients presenting with undescended testes, one or both are non-palpable. Whereas the most reliable means to exclude an abdominal testis is laparoscopy, there has been a lot of debate about the role of inguinal ultrasound (US) in detecting non-palpable inguinal testis. While we do not aim to add another paper claiming the benefits of US, we wanted to determine the excess capability of US to determine the correct surgical approach - inguinal or laparoscopy. In the light of avoiding unnecessary diagnostic laparoscopies, even the cost-effectiveness raised in many current papers might be called into question. Of a total of 684 boys who underwent surgery for undescended testes at our department between 2011 and 2014, in 58 (8.5%), one or both testes were neither palpable preoperatively nor under general anesthesia. These boys were examined by two experienced pediatric urologists clinically as well as by US. Besides the size of the contralateral testis, the presence of a testis in the inguinal channel was investigated. The additional impact of US over clinical exam and consideration of the size of the contralateral testis was assessed by means of intra-individual comparisons using Cochran-Q as well as McNemar tests. Clinical exam without considering the size of the contralateral testis had a sensitivity of 9% (95% CI 2-24%) and a specificity of 100% (95% CI 86-100%) to accurately predict the surgical approach deemed appropriate postoperatively. The consideration of the size of the contralateral testis - taken as an isolated factor - accurately predicted the surgical approach with a sensitivity of 21% (95% CI 9-38%) and a specificity of 88% (95% CI 68-97%). Ultrasound accounted for a sensitivity of 53% (95% CI 35-70%) and a specificity of 100% (95% CI 86-100%). The addition of US increased the sensitivity to correctly predict an inguinal incision from 29% to 71% and specificity slightly increased from 88% to 92%. This difference is significant (p = 0.008) in the bilateral McNemar test (Figure). Inguinal US of non-palpable testes and measurement of the contralateral testis are synergistic in predicting the surgical approach. The addition of ultrasound to a clinical exam, performed also under general anesthesia and by an experienced pediatric urologist significantly increases the prediction of the correct surgical approach. Our results translate into five boys needing an US of the NPT to prevent one laparoscopy. Whereas cost-effectiveness of US might be debatable in regard to different healthcare systems, it is proven to be an effective, non-harmful tool to avoid unnecessary diagnostic laparoscopies. Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Mammalian milk allergy: clinical suspicion, cross-reactivities and diagnosis.

PubMed

Järvinen, Kirsi M; Chatchatee, Pantipa

2009-06-01

Cow's milk allergy affects 2-3% of young children, the economic impact of which necessitates search for simple diagnostic tools and affordable milk substitutes. This review examines recent studies on the diagnosis of cow's milk allergy as well as on the allergenicity of milk from other mammalian species. Resolution of symptoms during strict milk avoidance and their re-appearance during the double-blind, placebo-controlled milk challenge remains the gold standard for the diagnosis of cow's milk allergy. Allergic eosinophilic esophagitis/gastroenteritis requires confirmatory endoscopic biopsy. There are increasing data in various populations on cut-off points based on positive predictive values for skin prick test and milk-specific IgE measurements to aid in the diagnosis of cow's milk allergy and to decrease the number of unnecessary food challenges. For non-IgE-mediated manifestations, noninvasive diagnostic tests are still largely lacking. The significant homology between milk from cow, sheep and goat results in clinical cross-reactivity. However, mare's or donkey's milk may be tolerated by some individuals. Data have been accumulating on the utility of diagnostic tools for mostly IgE-mediated milk allergy and allergenicity of milk from other mammalian species, although further studies are sought.

Endobronchial Ultrasound (EBUS) - Update 2017.

PubMed

Darwiche, Kaid; Özkan, Filiz; Wolters, Celina; Eisenmann, Stephan

2018-02-01

Endobronchial ultrasound (EBUS) has revolutionized the diagnosis of lung cancer over the last decade. This minimally invasive diagnostic method has also become increasingly important in the case of other diseases such as sarcoidosis, thereby helping to avoid unnecessary diagnostic interventions. This review article provides an update regarding EBUS and discusses current and future developments of this method. © Georg Thieme Verlag KG Stuttgart · New York.

Rapidly Progressive Osteoarthritis: a Review of the Clinical and Radiologic Presentation.

PubMed

Flemming, Donald J; Gustas-French, Cristy N

2017-07-01

The purpose of this paper is to review the distinct clinical and radiographic features that may lead to prompt diagnosis of rapidly progressive osteoarthritis (RPOA) and thus obviate unnecessary and costly diagnostic workup. RPOA is uncommon but is more frequently seen in practice because of the aging population. RPOA is a destructive arthropathy that occurs most commonly in elderly women but can also be seen in patients that have sustained trauma. The dramatic radiologic manifestations of RPOA can lead to diagnostic confusion with other arthropathies, infection, and osteonecrosis. RPOA was originally described in the hip but may also involve the shoulder. The etiology of RPOA is not well understood, but subchondral fracture probably plays a role in the development of dramatic destruction of the joint that is seen in affected patients. Early diagnosis may reduce the complexity of surgical management. RPOA is an uncommon condition that occurs most frequently in elderly woman or in patients who have sustained trauma. Prompt recognition of the clinical and radiologic features of this arthropathy can reduce unnecessary diagnostic workup and complexity of surgical intervention.

The clinical diagnostic reasoning process determining the use of endoscopy in diagnosing peptic ulcer disease.

PubMed

Gul, Naheed; Quadri, Mujtaba

2011-09-01

To evaluate the clinical diagnostic reasoning process as a tool to decrease the number of unnecessary endoscopies for diagnosing peptic ulcer disease. tudy Cross-sectional KAP study. Shifa College of Medicine, Islamabad, from April to August 2010. Two hundred doctors were assessed with three common clinical scenarios of low, intermediate and high pre-test probability for peptic ulcer disease using a questionnaire. The differences between the reference estimates and the respondents' estimates of pre-test and post test probability were used for assessing the ability of estimating the pretest probability and the post test probability of the disease. Doctors were also enquired about the cost-effectiveness and safety of endoscopy. Consecutive sampling technique was used and the data was analyzed using SPSS version 16. In the low pre-test probability settings, overestimation of the disease probability suggested the doctors' inability to rule out the disease. The post test probabilities were similarly overestimated. In intermediate pre-test probability settings, both over and under estimation of probabilities were noticed. In high pre-test probability setting, there was no significant difference in the reference and the responders' intuitive estimates of post test probability. Doctors were more likely to consider ordering the test as the disease probability increased. Most respondents were of the opinion that endoscopy is not a cost-effective procedure and may be associated with a potential harm. Improvement is needed in doctors' diagnostic ability by more emphasis on clinical decision-making and application of bayesian probabilistic thinking to real clinical situations.

Reducing the overuse of βhCG measurements in the emergency gynaecology clinic.

PubMed

Frost, Lucy

2016-01-01

Serial βhCG testing can be a helpful tool in deciding how to manage pregnancy of unknown location. Its use in emergency gynaecology clinics can prevent unnecessary admission and intervention. However, despite NICE Guidelines on when it is safe to opt for conservative management, it was identified that there was a problem with over-testing of βhCG when patients could be discharged with instructions to repeat a urinary pregnancy test in two weeks. Two PDSA cycles were undertaken to improve the awareness of NICE guidelines: the first involved formal and informal educational sessions and the second involved the inclusion of a guideline summary on the front of patients' notes when they were having serial βhCG tests for doctors to refer to. Case notes were reviewed for 157 women who had βhCG tests at baseline and 48 hours. Of these, 139 were suitable for serial βhCG testing, and 83 of these were suitable for discharge after 48 hours. Of the 83 patients that were eligible for discharge, there were 31 unnecessary βhCG tests done, 23 of which were prior to intervention. A significant improvement was noted, with between 4-10 unnecessary βhCG tests per fortnight prior to intervention, 0-3 following the first intervention, and 0-2 following the second. Reduction in unnecessary βhCG testing has positive implications for patients, who do not have to take unnecessary time off work, prolong an already very distressing period, and have unnecessary blood tests. There are also cost and time saving implications for the hospital.

Toward theragnostics.

PubMed

Pene, Frédéric; Courtine, Emilie; Cariou, Alain; Mira, Jean-Paul

2009-01-01

Theragnostics is a treatment strategy that combines therapeutics with diagnostics. It associates both a diagnostic test that identifies patients most likely to be helped or harmed by a new medication, and targeted drug therapy based on the test results. Bioinformatics, genomics, proteomics, and functional genomics are molecular biology tools essential for the progress of molecular theragnostics. These tools generate the genetic and protein information required for the development of diagnostic assays. Theragnostics includes a wide range of subjects, including personalized medicine, pharmacogenomics, and molecular imaging to develop efficient new targeted therapies with adequate benefit/risk to patients and a better molecular understanding of how to optimize drug selection. Furthermore, theragnostics aims to monitor the response to the treatment, to increase drug efficacy and safety. In addition, theragnostics could eliminate the unnecessary treatment of patients for whom therapy is not appropriate, resulting in significant drug cost savings for the healthcare system. However, the introduction of theragnostic tests into routine health care requires both a demonstration of cost-effectiveness and the availability of appropriate accessible testing systems. This review reports validation studies in oncology and infectious diseases that have demonstrated the benefits of such approach in well-defined subpopulations of patients, moving the field from the drug development process toward clinical practice and routine application. Theragnostics may change the usual business model of pharmaceutical companies from the classic blockbuster model toward targeted therapies.

Evaluation of the Luminex xTAG Respiratory Viral Panel FAST v2 assay for detection of multiple respiratory viral pathogens in nasal and throat swabs in Vietnam

PubMed Central

Thi Ty Hang, Vu; Thi Han Ny, Nguyen; My Phuc, Tran; Thi Thanh Tam, Pham; Thao Huong, Dang; Dang Trung Nghia, Ho; Tran Anh Vu, Nguyen; Thi Hong Phuong, Pham; Van Xang, Nguyen; Dong, Nguyen; Nhu Hiep, Pham; Van Hung, Nguyen; Tinh Hien, Tran; Rabaa, Maia; Thwaites, Guy E.; Baker, Stephen; Van Tan, Le; van Doorn, H.Rogier

2018-01-01

Background: Acute respiratory infections (ARI) are among the leading causes of hospitalization in children ≤5 years old. Rapid diagnostics of viral pathogens is essential to avoid unnecessary antibiotic treatment, thereby slowing down antibiotic-resistance. We evaluated the diagnostic performance of the Luminex xTAG Respiratory Viral Panel FAST v2 against viral specific PCR as reference assays for ARI in Vietnam. Methods: Four hundred and forty two nose and throat swabs were collected in viral transport medium, and were tested with Luminex xTAG Respiratory Viral Panel FAST v2. Multiplex RT-PCR and single RT-PCR were used as references.    Results: Overall, sensitivity of the Luminex against reference assays was 91.8%, 95% CI 88.1-94.7 (270/294), whilst 112/6336 (1.8%, 95% CI, 1.4-2.1) of pathogens were detected by the Luminex, but not by reference assays. Frequency of pathogens detected by Luminex and reference assays was 379 and 292, respectively. The diagnostic yield was 66.7% (295/442, 95%CI 62.1-71.1%) for the Luminex assay and 54.1% (239/442, 95% CI, 49.3-58.8%) for reference assays. The Luminex kit had higher yields for all viruses except influenza B virus, respiratory syncytial virus, and human bocavirus. High agreements between both methods [mean (range): 0.91 (0.83-1.00)] were found for 10/15 viral agents. Conclusions: The Luminex assay is a high throughput multiplex platform for rapid detection of common viral pathogens causing ARI. Although the current high cost may prevent Luminex assays from being widely used, especially in limited resource settings where ARI are felt most, its introduction in clinical diagnostics may help reduce unnecessary use of antibiotic prescription. PMID:29503874

Impact of GeneXpert MTB/RIF assay on triage of respiratory isolation rooms for inpatients with presumed tuberculosis: a hypothetical trial.

PubMed

Chaisson, Lelia H; Roemer, Marguerite; Cantu, David; Haller, Barbara; Millman, Alexander J; Cattamanchi, Adithya; Davis, J Lucian

2014-11-15

Placing inpatients with presumed active pulmonary tuberculosis in respiratory isolation pending results of serial sputum acid-fast bacilli (AFB) smear microscopy is standard practice in high-income countries. However, this diagnostic strategy is slow and yields few tuberculosis diagnoses. We sought to determine if replacing microscopy with the GeneXpert MTB/RIF (Xpert) nucleic acid amplification assay could reduce testing time and usage of isolation rooms. We prospectively followed inpatients at San Francisco General Hospital undergoing tuberculosis evaluation. We performed smear microscopy and Xpert testing on concentrated sputum, and calculated diagnostic accuracy for both strategies in reference to serial sputum mycobacterial culture. We measured turnaround time for microscopy and estimated hypothetical turnaround times for Xpert on concentrated and unconcentrated sputum. We compared median and total isolation times for microscopy to those estimated for the 2 Xpert strategies. Among 139 patients with 142 admissions, median age was 54 years (interquartile range [IQR], 43-60 years); 32 (23%) patients were female, and 42 (30%) were HIV seropositive. Serial sputum smear microscopy and a single concentrated sputum Xpert had identical sensitivity (89%; 95% confidence interval [CI], 52%-100%) and similar specificity (99% [95% CI, 96%-100%] vs 100% [95% CI, 97%-100%]). A single concentrated sputum Xpert could have saved a median of 35 hours (IQR, 24-36 hours) in unnecessary isolation compared with microscopy, and a single unconcentrated sputum Xpert, 45 hours (IQR, 35-46 hours). Replacing serial sputum smear microscopy with a single sputum Xpert could eliminate most unnecessary isolation for inpatients with presumed tuberculosis, greatly benefiting patients and hospitals. © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

[Usefulness of imaging examinations in preoperative diagnosis of acute appendicitis].

PubMed

Nitoń, Tomasz; Górecka-Nitoń, Aleksandra

2014-01-01

Acute appendicitis (AA) is the cause one of most operations perform in department of general surgery on emergency ward. Frequency of acute appendicitis range from 6-8% of population. Clinical presentation is frequently unspecified and despite common occurence leads to many difficulties in diagnosis. Diagnosis of acute appendicitis includes clinical examination, laboratory tests, diagnostic scoring systems, computer programs as physisian aids and imaging examinations. About 30-45% patients suspected of acute appendicitis have untypical clinical presentation and here use of US or CT is very helpful. Longstanding use of US resulted in high AA evaluation accuracy with high sensitivity (75-90%) and specificity (84-100%). CT demonstrates above 95% ratio of correct diagnoses, reduces negative appendectomy rates and perforation rates as well as unnecessary observations. CT sensitivity and specificity CT is estimated between 83-100% among different authors. Expedited AA diagnosis, surgery and reduced hospitalization time are possible advantages of imaging tests. Additionally these tests can detect alternative deseases imitating acute appnedicitis. Use of imaging tests especially CT is beneficial in fertile women because of frequent genito-urinary disorders leading to the most diagnostic errors. However thera are contraindications in use of CT, for example it can not be performed in early pregnancy etc...

The diagnostic value of troponin T testing in the community setting.

PubMed

Planer, David; Leibowitz, David; Paltiel, Ora; Boukhobza, Rina; Lotan, Chaim; Weiss, Teddy A

2006-03-08

Many patients presenting with chest pain to their family physician are referred to the emergency room, in part, due to lack of accurate objective diagnostic tools. This study aimed to assess the diagnostic value of bedside troponin T kit testing in patients presenting with chest pain to their family physician. Prospective, multi-center study. Consecutive subjects with chest pain were recruited from 44 community clinics in Jerusalem. Following clinical assessment by the family physician, qualitative troponin kit testing was performed. Patients with a negative clinical assessment and negative troponin kit were sent home and all others were referred to the emergency room. The final diagnosis at the time of hospital discharge was recorded and telephone follow up was performed after 60 days. Positive predictive value, negative predictive value, sensitivity and specificity of troponin kit for myocardial infarction diagnosis and of family physician for hospitalization, were assessed. Of 392 patients enrolled, 349 (89%) were included in the final analysis. The prevalence of myocardial infarction was 1.7%. The positive and negative predictive values of the troponin kit for myocardial infarction diagnosis were 100% and 99.7%, respectively. The positive and negative predictive values of the family physician's assessment to predict hospitalization were 41.4% and 94.1%, respectively. Troponin kit testing is an important tool to assist the family physician in the assessment of patients with chest pain in the community setting. Troponin kit testing may identify otherwise undiagnosed cases of myocardial infarctions, and reduce unnecessary referrals to the emergency room.

Aetiological diagnosis of child deafness: CODEPEH recommendations.

PubMed

Núñez-Batalla, Faustino; Jáudenes-Casaubón, Carmen; Sequí-Canet, Jose Miguel; Vivanco-Allende, Ana; Zubicaray-Ugarteche, Jose; Cabanillas-Farpón, Rubén

Important progress in the fields of molecular genetics (principally) and diagnostic imaging, together with the lack of a consensus protocol for guiding the diagnostic process after confirming deafness by neonatal screening, have led to this new work document drafted by the Spanish Commission for the Early Detection of Child Deafness (Spanish acronym: CODEPEH). This 2015 Recommendations Document, which is based on the most recent scientific evidence, provides guidance to professionals to support them in making decisions regarding aetiological diagnosis. Such diagnosis should be performed without delay and without impeding early intervention. Early identification of the causes of deafness offers many advantages: it prevents unnecessary trouble for the families, reduces health system expenses caused by performing different tests, and provides prognostic information that may guide therapeutic actions. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. All rights reserved.

Juvenile retinoschisis: a model for molecular diagnostic testing of X-linked ophthalmic disease.

PubMed

Sieving, P A; Yashar, B M; Ayyagari, R

1999-01-01

X-linked juvenile retinoschisis (RS) provides a starting point to define clinical paradigms and understand the limitations of diagnostic molecular testing. The RS phenotype is specific, but the broad severity range is clinically confusing. Molecular diagnostic testing obviates unnecessary examinations for boys at-risk and identifies carrier females who otherwise show no clinical signs. The XLRS1 gene has 6 exons of 26-196 base-pair size. Each exon is amplified by a single polymerase chain reaction and then sequenced, starting with exons 4 through 6, which contain mutation "hot spots." The 6 XLRS1 exons are sequenced serially. If alterations are found, they are compared with mutations in our > 120 XLRS families and with the > 300 mutations reported worldwide. Point mutations, small deletions, or rearrangements are identified in nearly 90% of males with a clinical diagnosis of RS. XLRS1 has very few sequence polymorphisms. Carrier-state testing produces 1 of 3 results: (1) positive, in which the woman has the same mutation as an affected male relative or known in other RS families; (2) negative, in which she lacks the mutation of her affected male relative; and (3) uninformative, in which no known mutation is identified or no information exists about the familial mutation. Molecular RS screening is an effective diagnostic tool that complements the clinician's skills for early detection of at-risk males. Useful outcomes of carrier testing depend on several factors: (1) a male relative with a clear clinical diagnosis; (2) a well-defined inheritance pattern; (3) high disease penetrance; (4) size and organization of the gene; and (5) the types of disease-associated mutations. Ethical questions include molecular diagnostic testing of young at-risk females before the age of consent, the impact of this information on the emotional health of the patient and family, and issues of employability and insurance coverage.

Juvenile retinoschisis: a model for molecular diagnostic testing of X-linked ophthalmic disease.

PubMed Central

Sieving, P A; Yashar, B M; Ayyagari, R

1999-01-01

BACKGROUND AND PURPOSE: X-linked juvenile retinoschisis (RS) provides a starting point to define clinical paradigms and understand the limitations of diagnostic molecular testing. The RS phenotype is specific, but the broad severity range is clinically confusing. Molecular diagnostic testing obviates unnecessary examinations for boys at-risk and identifies carrier females who otherwise show no clinical signs. METHODS: The XLRS1 gene has 6 exons of 26-196 base-pair size. Each exon is amplified by a single polymerase chain reaction and then sequenced, starting with exons 4 through 6, which contain mutation "hot spots." RESULTS: The 6 XLRS1 exons are sequenced serially. If alterations are found, they are compared with mutations in our > 120 XLRS families and with the > 300 mutations reported worldwide. Point mutations, small deletions, or rearrangements are identified in nearly 90% of males with a clinical diagnosis of RS. XLRS1 has very few sequence polymorphisms. Carrier-state testing produces 1 of 3 results: (1) positive, in which the woman has the same mutation as an affected male relative or known in other RS families; (2) negative, in which she lacks the mutation of her affected male relative; and (3) uninformative, in which no known mutation is identified or no information exists about the familial mutation. CONCLUSIONS: Molecular RS screening is an effective diagnostic tool that complements the clinician's skills for early detection of at-risk males. Useful outcomes of carrier testing depend on several factors: (1) a male relative with a clear clinical diagnosis; (2) a well-defined inheritance pattern; (3) high disease penetrance; (4) size and organization of the gene; and (5) the types of disease-associated mutations. Ethical questions include molecular diagnostic testing of young at-risk females before the age of consent, the impact of this information on the emotional health of the patient and family, and issues of employability and insurance coverage. Images FIGURE 2A FIGURE 2B PMID:10703138

The most common mistakes on dermatoscopy of melanocytic lesions

PubMed Central

Kamińska-Winciorek, Grażyna

2015-01-01

Dermatoscopy is a method of in vivo evaluation of the structures within the epidermis and dermis. Currently, it may be the most precise pre-surgical method of diagnosing melanocytic lesions. Diagnostic errors may result in unnecessary removal of benign lesions or what is even worse, they can cause early and very early melanomas to be overlooked. Errors in assessment of dermatoscopy can be divided into those arising from failure to maintain proper test procedures (procedural and technical errors) and knowledge based mistakes related to the lack of sufficient familiarity and experience in dermatoscopy. The article discusses the most common mistakes made by beginner or inexperienced dermatoscopists. PMID:25821425

Cotton Fever: A Condition Self-Diagnosed by IV Drug Users.

PubMed

Zerr, Ashley Michelle; Ku, Kimberly; Kara, Areeba

2016-01-01

The presentation of fever in an intravenous drug user prompts diagnostic testing targeted at identifying infectious etiologies. However, an alternate diagnosis exists in "cotton fever." While few reports describe this phenomenon in the peer-reviewed literature, the diagnosis is well recognized among the intravenous drug user community. Although its etiology is not well understood, cotton fever seems to be a self-limited, febrile response to the intravenous administration of a drug filtered through cotton. Educating clinicians regarding cotton fever may limit unnecessary hospital admissions and improve our ability to care for this population. © Copyright 2016 by the American Board of Family Medicine.

The use of a pocket-sized ultrasound device improves physical examination: results of an in- and outpatient cohort study.

PubMed

Colli, Agostino; Prati, Daniele; Fraquelli, Mirella; Segato, Sergio; Vescovi, Pier Paolo; Colombo, Fabrizio; Balduini, Carlo; Della Valle, Serena; Casazza, Giovanni

2015-01-01

The performance of pocket mobile ultrasound devices (PUDs) is comparable with that of standard ultrasonography, whereas the accuracy of a physical examination is often poor requiring further tests to assess diagnostic hypotheses. Adding the use of PUD to physical examination could lead to an incremental benefit. We assessed whether the use of PUD in the context of physical examination can reduce the prescription of additional tests when used by physicians in different clinical settings. We conducted a cohort impact study in four hospital medical wards, one gastroenterological outpatient clinic, and 90 general practices in the same geographical area. The study involved 135 physicians who used PUD, after a short predefined training course, to examine 1962 consecutive patients with one of 10 diagnostic hypotheses: ascites, pleural effusion, pericardial effusion, urinary retention, urinary stones, gallstones, biliary-duct dilation, splenomegaly, abdominal mass, abdominal aortic aneurysm. According to the physicians' judgment, PUD examination could rule out or in the diagnostic hypothesis or require further testing; the concordance with the final diagnosis was assessed. The main outcome was the proportion of cases in which additional tests were required after PUD. The PUD diagnostic accuracy was assessed in patients submitted to further testing. The 1962 patients included 37% in-patients, 26% gastroenterology outpatients, 37% from general practices. Further testing after PUD examination was deemed unnecessary in 63%. Only 5% of patients with negative PUD not referred for further testing were classified false negatives with respect to the final diagnosis. In patients undergoing further tests, the sensitivity was 91%, and the specificity 83%. After a simple and short training course, a PUD examination can be used in addition to a physical examination to improve the answer to ten common clinical questions concerning in- and outpatients, and can reduce the need for further testing.

Quantitative Value of Aldosterone-Renin Ratio for Detection of Aldosterone-Producing Adenoma: The Aldosterone-Renin Ratio for Primary Aldosteronism (AQUARR) Study.

PubMed

Maiolino, Giuseppe; Rossitto, Giacomo; Bisogni, Valeria; Cesari, Maurizio; Seccia, Teresa Maria; Plebani, Mario; Rossi, Gian Paolo

2017-05-21

Current guidelines recommend use of the aldosterone-renin ratio (ARR) for the case detection of primary aldosteronism followed by confirmatory tests to exclude false-positive results from further diagnostic workup. We investigated the hypothesis that this could be unnecessary in patients with a high ARR value if the quantitative information carried by the ARR is taken into due consideration. We interrogated 2 large data sets of prospectively collected patients studied with the same predefined protocol, which included the captopril challenge test. We used an unambiguous diagnosis of aldosterone-producing adenoma as reference index. We also assessed whether the post-captopril ARR and plasma aldosterone concentration fall furnished a diagnostic gain over baseline ARR values. We found that the false-positive rate fell exponentially, and, conversely, the specificity increased with rising ARR values. At receiver operating characteristics curves and diagnostic odds ratio analysis, the high baseline ARR values implied very high positive likelihood ratio and diagnostic odds ratio values. The baseline and post-captopril ARR showed similar diagnostic accuracy (area under the receiver operating characteristics curve) in both the exploratory and validation cohorts, indicating lack of diagnostic gain with this confirmatory test (between-area under the curve difference, 0.005; 95% CI, -0.031 to 0.040; P =0.7 for comparison, and 0.05; 95% CI, -0.061 to 0.064; P =0.051 for comparison, respectively). These results indicate that the ARR conveys key quantitative information that, if properly used, can simplify the diagnostic workup, resulting in saving of money and resources. This can offer the chance of diagnosis and ensuing adrenalectomy to a larger number of hypertensive patients, ultimately resulting in better control of blood pressure. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

The Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity

PubMed Central

Al-Hameed, Fahad; Al-Dorzi, Hasan M; Shamy, Abdulrahman; Qadi, Abdulelah; Bakhsh, Ebtisam; Aboelnazar, Essam; Abdelaal, Mohamad; Al Khuwaitir, Tarig; Al-Moamary, Mohamed S.; Al-Hajjaj, Mohamed S.; Brozek, Jan; Schünemann, Holger; Mustafa, Reem; Falavigna, Maicon

2015-01-01

The diagnosis of deep venous thrombosis (DVT) may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia (KSA), an expert panel led by the Saudi Association for Venous Thrombo-Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay (ELISA) and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended. PMID:25593601

Evaluation of a rapid immunodiagnostic test kit for rabies virus.

PubMed

Kang, BoKyu; Oh, JinSik; Lee, ChulSeung; Park, Bong-Kyun; Park, YoungNam; Hong, KyungSoo; Lee, KyungGi; Cho, ByungKi; Song, DaeSub

2007-10-01

A rapid immunodiagnostic test kit for rabies virus detection was evaluated using 51 clinical samples and 4 isolates of rabies virus. The quick detection of rabies virus under field conditions may be helpful in determining if post-exposure prophylaxis is needed, thereby avoiding unnecessary treatments, as well as undue economic burden. There are several widely used diagnostic methods for rabies, including fluorescent antibody tests, reverse transcription polymerase chain reaction, and electron microscopy; however, these methods include time-consuming, intricate, and costly procedures. The rapid immunodiagnostic test was able to detect rabies virus in clinical samples, including brain tissue and saliva, in addition to 10(3.2) 50% lethal dose (LD(50))/mL cell-adapted rabies virus. The assay was not cross-reactive with non-rabies virus microbes. When the performance of the rapid immunodiagnostic test was compared to a fluorescent antibody test, the rapid immunodiagnostic test had a sensitivity of 91.7% and specificity of 100% (95.8% CI).

Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care--a Rome Foundation working team report.

PubMed

Hungin, A P S; Molloy-Bland, M; Claes, R; Heidelbaugh, J; Cayley, W E; Muris, J; Seifert, B; Rubin, G; de Wit, N

2014-11-01

To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care. Systematic searches of PubMed and Embase. Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)]. There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians. © 2014 John Wiley & Sons Ltd.

Lipase or amylase for the diagnosis of acute pancreatitis?

PubMed

Ismail, Ola Z; Bhayana, Vipin

2017-12-01

Acute pancreatitis is a rapid onset of inflammation of the pancreas causing mild to severe life threatening conditions [1, 2]. In Canada, acute pancreatitis is the 5th most expensive digestive disease in Canada with a considerable economic burden on the health care system [3]. The diagnosis of acute pancreatitis is usually based on the presence of abdominal pain and elevated levels of serum amylase and/or lipase. Many health care centers use either serum amylase, lipase or both to diagnose acute pancreatitis without considering which one could provide a better diagnostic accuracy. The aim of this review is to investigate whether serum lipase alone is a sufficient biomarker for the diagnosis of acute pancreatitis. We have examined various studies looking at the utilization, sensitivity, specificity and cost associated savings of lipase and amylase in the diagnosis of acute pancreatitis. When comparing different studies, serum lipase offers a higher sensitivity than serum amylase in diagnosing acute pancreatitis. Lipase also offers a larger diagnostic window than amylase since it is elevated for a longer time, thus allowing it to be a useful diagnostic biomarker in early and late stages of acute pancreatitis. Several recent evidence-based guidelines recommend the use of lipase over amylase. Nevertheless, both lipase and amylase alone lack the ability to determine the severity and etiology of acute pancreatitis. The co-ordering of both tests has shown little to no increase in the diagnostic sensitivity and specificity. Thus, unnecessary testing and laboratory expenditures can be reduced by testing lipase alone. Copyright © 2017 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Background Report: Recommendations on Guidance for Diagnostic X-Ray Studies in Federal Health Care Facilities

EPA Pesticide Factsheets

This document shares the guidance developed by the Interagency Working Group which was formed to develop guidance to reduce unnecessary radiation exposures from the use of x-rays in the healing arts in Federal health care facilities.

Multiplex molecular testing for management of infectious gastroenteritis in a hospital setting: a comparative diagnostic and clinical utility study.

PubMed

Halligan, E; Edgeworth, J; Bisnauthsing, K; Bible, J; Cliff, P; Aarons, E; Klein, J; Patel, A; Goldenberg, S

2014-08-01

Laboratory diagnosis and clinical management of inpatients with diarrhoea is complex and time consuming. Tests are often requested sequentially and undertaken in different laboratories. This causes prolonged unnecessary presumptive isolation of patients, because most cases are non-infectious. A molecular multiplex test (Luminex(®) Gastrointestinal Pathogen Panel (GPP)) was compared with conventional testing over 8 months to determine diagnostic accuracy, turnaround times, laboratory costs, use of isolation facilities and user acceptability. A total of 262 (12%) patients had a pathogen detected by conventional methods compared with 483 (22.1%) by GPP. Most additional cases were detected in patients developing symptoms in the first 4 days of admission. Additional cases were detected because of presumed improved diagnostic sensitivity but also because clinicians had not requested the correct pathogen. Turnaround time (41.8 h) was faster than bacterial culture (66.5 h) and parasite investigation (66.5 h) but slower than conventional testing for Clostridium difficile (17.3 h) and viruses (27 h). The test could allow simplified requesting by clinicians and a consolidated laboratory workflow, reducing the overall number of specimens received by the laboratory. A total of 154 isolation days were saved at an estimated cost of £30 800. Consumables and labour were estimated at £150 641 compared with £63 431 for conventional testing. Multiplex molecular testing using a panel of targets allowed enhanced detection and a consolidated laboratory workflow. This is likely to be of greater benefit to cases that present within the first 4 days of hospital admission. © 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.

Overuse of Diagnostic Imaging for Work-Related Injuries.

PubMed

Clendenin, Brianna Rebecca; Conlon, Helen Acree; Burns, Candace

2017-02-01

Overuse of health care in the United States is a growing concern. This article addresses the use of diagnostic imaging for work-related injuries. Diagnostic imaging drives substantial cost for increases in workers' compensation. Despite guidelines published by the American College of Radiology and the American College of Occupational Medicine and the Official Disability Guidelines, practitioners are prematurely ordering imaging sooner than recommended. Workers are exposed to unnecessary radiation and are incurring increasing costs without evidence of better outcomes. Practitioners caring for workers and submitting workers' compensation claims should adhere to official guidelines, using their professional judgment to consider financial impact and health outcomes of diagnostic imaging including computed tomography, magnetic resonance imaging, nuclear medicine imaging, radiography, and ultrasound.

Reliability of the nerve conduction monitor in repeated measures of median and ulnar nerve latencies

DOE Office of Scientific and Technical Information (OSTI.GOV)

Washington, I A

According to the Bureau of Labor Statistics, carpal tunnel syndrome (CTS), one of the most rapidly growing work-related injuries, cost American businesses up to $10 billion dollars in medical costs each year (1992). Because conservative therapy can be implemented and CTS is more reversible in it early stages, early detection will not only save industry unnecessary health care costs, but also prevent employees from experiencing debilitating pain and unnecessary surgery. In response to the growing number of cases of CTS, many companies have introduced screening tools to detect early stages of carpal tunnel syndrome. Neurotron Medical (New Jersey) has designedmore » a portable nerve conduction monitor (Nervepace S-200) which measures motor and sensory nerve latencies. The slowing of these latencies is one diagnostic indicator of carpal tunnel syndrome. In this study, we determined the reliability of the Nervepace Monitor in measure ulnar and median nerve latencies during repeated testing. The testing was performed on 28 normal subjects between the ages of 20 and 35 who had no prior symptoms of CTS. They were tested at the same time each day for three consecutive days. Nerve latencies between different ethnic groups and genders were compared. Results show that there was no significant daily variation of the median motor and lunar sensory latencies or the median sensory latencies. No significant differences of latencies was observed among ethnic groups; however, a significant difference of latencies between male and female subjects was observed (p<0.05).« less

[Recommendations for the use of rapid diagnosis techniques in respiratory infections in primary care].

PubMed

Llor, Carles; Alkorta Gurrutxaga, Miriam; de la Flor I Bru, Josep; Bernárdez Carracedo, Sílvia; Cañada Merino, José Luis; Bárcena Caamaño, Mario; Serrano Martino, Carmen; Cots Yago, Josep Maria

Respiratory tract infections rank first as causes of adult and paediatric infectious morbidity in primary care in Spain. These infections are usually self-limiting and are mainly caused by viruses. However, a high percentage of unnecessary antibiotic prescription is reported. Point-of-care tests are biomedical tests, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is rapidly increasing in general practice. Notwithstanding, we must mull over whether they always contribute to an effective and high-quality diagnostic process by primary care clinicians. We present a set of criteria that can be used by clinicians and discuss the pros and cons of the instruments available for the management of respiratory tract infections and how to use them appropriately. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

[Unnecessary routine laboratory tests in patients referred for surgical services].

PubMed

Mata-Miranda, María del Pilar; Cano-Matus, Norberto; Rodriguez-Murrieta, Margarita; Guarneros-Zapata, Idalia; Ortiz, Mario

2016-01-01

To question the usefulness of the lab analysis considered routine testing for the identification of abnormalities in the surgical care. To determine the percentage of unnecessary laboratory tests in the preoperative assessment as well as to estimate the unnecessary expenses. A descriptive, cross-sectional study of patients referred for surgical evaluation between January 1st and March 31st 2013. The database of laboratory testing and electronic files were reviewed. Reference criteria from surgical services were compared with the tests requested by the family doctor. In 65% of the patients (n=175) unnecessary examinations were requested, 25% (n=68) were not requested the tests that they required, and only 10% of the patients were requested laboratory tests in accordance with the reference criteria (n=27). The estimated cost in unnecessary examinations was $1,129,552 in a year. The results were similar to others related to this theme, however, they had not been revised from the perspective of the first level of attention regarding the importance of adherence to the reference criteria which could prevent major expenditures. It is a priority for leaders and operational consultants in medical units to establish strategies and lines of action that ensure compliance with institutional policies so as to contain spending on comprehensive services, and which in turn can improve the medical care. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Methodology and technical requirements of the galectin-3 test for the preoperative characterization of thyroid nodules.

PubMed

Bartolazzi, Armando; Bellotti, Carlo; Sciacchitano, Salvatore

2012-01-01

In the last decade, the β-galactosyl binding protein galectin-3 has been the object of extensive molecular, structural, and functional studies aimed to clarify its biological role in cancer. Multicenter studies also contributed to discover the potential clinical value of galectin-3 expression analysis in distinguishing, preoperatively, benign from malignant thyroid nodules. As a consequence galectin-3 is receiving significant attention as tumor marker for thyroid cancer diagnosis, but some conflicting results mostly owing to methodological problems have been published. The possibility to apply preoperatively a reliable galectin-3 test method on fine needle aspiration biopsy (FNA)-derived thyroid cells represents an important achievement. When correctly applied, the method reduces consistently the gray area of thyroid FNA cytology, contributing to avoid unnecessary thyroid surgery. Although the efficacy and reliability of the galectin-3 test method have been extensively proved in several studies, its translation in the clinical setting requires well-standardized reagents and procedures. After a decade of experimental work on galectin-3-related basic and translational research projects, the major methodological problems that may potentially impair the diagnostic performance of galectin-3 immunotargeting are highlighted and discussed in detail. A standardized protocol for a reliable galectin-3 expression analysis is finally provided. The aim of this contribution is to improve the clinical management of patients with thyroid nodules, promoting the preoperative use of a reliable galectin-3 test method as ancillary technique to conventional thyroid FNA cytology. The final goal is to decrease unnecessary thyroid surgery and its related social costs.

Choosing the right diagnostic imaging modality in musculoskeletal diagnosis.

PubMed

Aagesen, Andrea L; Melek, Maged

2013-12-01

Radiological studies can confirm or rule out competing diagnoses for musculoskeletal injuries and pain. Obtaining a detailed history and physical examination is pivotal for localizing the pain generator and choosing the most appropriate imaging studies, based on the suspected injured tissue. Judicious use of imaging is important to avoid unnecessary radiation exposure, minimize cost, and avoid therapy targeting asymptomatic imaging abnormalities. This article compares and contrasts the diagnostic imaging commonly used for detecting musculoskeletal injuries. Copyright © 2013 Elsevier Inc. All rights reserved.

Development and prospective multicenter evaluation of the long noncoding RNA MALAT-1 as a diagnostic urinary biomarker for prostate cancer

PubMed Central

Lu, Ji; Shi, Xiaolei; Zhu, Yasheng; Zhang, Wei; Jing, Taile; Zhang, Chao; Shen, Jian; Xu, Chuanliang; Wang, Huiqing; Wang, Haifeng; Wang, Yang; Liu, Bin; Li, Yaoming; Fang, Ziyu; Guo, Fei; Qiao, Meng; Wu, Chengyao; Wei, Qiang; Xu, Danfeng; Shen, Dan; Lu, Xin; Gao, Xu; Hou, Jianguo; Sun, Yinghao

2014-01-01

The current strategy for diagnosing prostate cancer (PCa) is mainly based on the serum prostate-specific antigen (PSA) test. However, PSA has low specificity and has led to numerous unnecessary biopsies. We evaluated the effectiveness of urinary metastasis-associated lung adenocarcinoma transcript 1 (MALAT-1), a long noncoding RNA, for predicting the risk of PCa before biopsy. The MALAT-1 score was tested in a discovery phase and a multi-center validation phase. The predictive power of the MALAT-1 score was evaluated by the area under receiver operating characteristic (ROC) curve (AUC) and by decision curve analysis. As an independent predictor of PCa, the MALAT-1 score was significantly higher in men with a positive biopsy than in those with a negative biopsy. The ROC analysis showed a higher AUC for the MALAT-1 score (0.670 and 0.742) vs. the total PSA (0.545 and 0.601) and percent free PSA (0.622 and 0.627) in patients with PSA values of 4.0-10 ng/ml. According to the decision curve analysis, using a probability threshold of 25%, the MALAT-1 model would prevent 30.2%-46.5% of unnecessary biopsies in PSA 4–10 ng/ml cohorts, without missing any high-grade cancers. Our results demonstrate that urine MALAT-1 is a promising biomarker for predicting prostate cancer risk. PMID:25526029

Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts.

PubMed

Yehia, Baligh R; Herati, Ramin S; Fleishman, John A; Gallant, Joel E; Agwu, Allison L; Berry, Stephen A; Korthuis, P Todd; Moore, Richard D; Metlay, Joshua P; Gebo, Kelly A

2014-01-01

Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.

Macrocytic anemia in Lesch-Nyhan disease and its variants.

PubMed

Cakmakli, Hasan F; Torres, Rosa J; Menendez, Araceli; Yalcin-Cakmakli, Gul; Porter, Christopher C; Puig, Juan Garcia; Jinnah, H A

2018-06-06

Lesch-Nyhan disease is an inherited metabolic disorder characterized by overproduction of uric acid and neurobehavioral abnormalities. The purpose of this study was  to describe macrocytic erythrocytes as another common aspect of the phenotype. The results of 257 complete blood counts from 65 patients over a 23-year period were collected from 2 reference centers where many patients are seen regularly. Macrocytic erythrocytes occurred in 81-92% of subjects with Lesch-Nyhan disease or its neurological variants. After excluding cases with iron deficiency because it might pseudonormalize erythrocyte volumes, macrocytosis occurred in 97% of subjects. Macrocytic erythrocytes were sometimes accompanied by mild anemia, and rarely by severe anemia. These results establish macrocytic erythrocytes as a very common aspect of the clinical phenotype of Lesch-Nyhan disease and its neurological variants. Macrocytosis is so characteristic that its absence should prompt suspicion of a secondary process, such as iron deficiency. Because macrocytosis is uncommon in unaffected children, it can also be used as a clue for early diagnosis in children with neurodevelopmental delay. Better recognition of this characteristic feature of the disorder will also help to prevent unnecessary diagnostic testing and unnecessary attempts to treat it with folate or B12 supplements.

[Effects of biphasic spiral CT, conventional and iron oxide enhanced MRI on therapy and therapy costs in patients with focal liver lesions].

PubMed

Helmberger, T; Gregor, M; Holzknecht, N; Rau, H; Scheidler, J; Reiser, M

2000-03-01

Evaluation of the diagnostic efficacy and cost-benefit of contrast enhanced CT (CT) and MRI pre- and post-SPIO-particles in focal hepatic disease with consideration of therapeutic outcome. In 52 patients with the suspicion of primary or secondary hepatic malignancy, biphasic spiral CT and breath-hold gradient-echo T1- and fast spin-echo T2-weighted MRI pre- and post-iron oxide administration (1.5 T, body-phased-array coil) were compared. The number of hepatic lesions and the related diagnoses resulting from each imaging modality were recorded and statistically correlated to the final diagnoses established by biopsy/OP (34/52), long term follow-up of 12 months (18/52), and a consensus reading of all imaging modalities considering all clinical imaging information. The most likely induced therapy resulting from each imaging test was correlated to the final therapy. Based on data from the hospitals accountants, the therapy-related costs were estimated without hospitalization costs. In 34/52 (65.4%) of the cases the correct diagnosis was primarily stated by CT (sensitivity [se.] 85.2%, specificity [sp.] 44.0%). In additional 10/52 of the cases unenhanced MRI (se. 91.4%, sp. 75.0%) enabled correct diagnoses, and in another 6 cases the diagnosis was established only by SPIO-MRI (se. 100%, sp. 86.7%). Considering the possible therapeutic recommendation arising from each modality, CT would have induced needles therapy costs of 191,042 DM, unenhanced MRI of 171,035 DM, and SPIO-MRI of 7,311 DM. In comparison to the real therapy costs of 221,873 DM, this would have corresponded to an unnecessary increase of therapy costs of 86.1%, 77.1%, and 3.3%, respectively. In two cases (1 hemangioma, 1 regenerative nodule) all modalities failed, causing unnecessary surgery in one patient. In this problem-oriented scenario unenhanced and SPIO-enhanced MRI proved to be superior to CT regarding diagnostic efficacy. The cost-benefit resulted mainly due to preserving patients from unnecessary surgical procedures.

Integrating Hospital-Acquired Lessons into Community Health Practice: Optimizing Antimicrobial Use in Bangalore

ERIC Educational Resources Information Center

Biswas, Rakesh; Dineshan, Vineeth; Narasimhamurthy, N. S.; Kasthuri, A. S.

2007-01-01

Introduction: Even as antimicrobial resistance is a serious public health concern worldwide, the uncertainties of diagnosis and treatment of fever strongly influence community practitioners toward prescribing antibiotics. To help community practitioners resolve their diagnostic questions and reduce the unnecessary use of antibiotics for viral…

76 FR 39159 - Schedule for Rating Disabilities; The Digestive System

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-05

... commenter suggested that we evaluate gastrectomy and vagotomy- pyloroplasty under the same criteria. The... in order to evaluate it. This material is unnecessary, since there are separate diagnostic codes for....113. We propose to direct the rater to separately evaluate two or more conditions in Sec. 4.114 only...

Protocol for diagnostic test accuracy study: the efficacy of screening for common dental diseases by Dental Care Professionals

PubMed Central

2013-01-01

Background The bulk of service delivery in dentistry is delivered by general dental practitioners, when a large proportion of patients who attend regularly are asymptomatic and do not require treatment. This represents a substantial and unnecessary cost, given that it is possible to delegate a range of tasks to dental care professionals, who are a less expensive resource. Screening for the common dental diseases by dental care professionals has the potential to release general dental practitioner’s time and increase the capacity to care for those who don't currently access services. The aim of this study is to compare the diagnostic test accuracy of dental care professionals when screening for dental caries and periodontal disease in asymptomatic adults aged eighteen years of age. Methods/design Ten dental practices across the North-West of England will take part in a diagnostic test accuracy study with 200 consecutive patients in each practice. The dental care professionals will act as the index test and the general dental practitioner will act as the reference test. Consenting asymptomatic patients will enter the study and see either the dental care professionals or general dental practitioner first to remove order effects. Both sets of clinicians will make an assessment of dental caries and periodontal disease and enter their decisions on a record sheet for each participant. The primary outcome measure is the diagnostic test accuracy of the dental care professionals and sensitivity, specificity, positive predictive value and negative predictive values will be reported. A number of clinical factors will be assessed for confounding. Discussion The results of this study will determine whether dental care professionals can screen for the two most prevalent oral diseases. This will inform the literature and is apposite given the recent policy change in the United Kingdom towards direct access. PMID:24053760

Analysis of the diagnostic pathway and delay in patients with amyotrophic lateral sclerosis in the Valencian Community.

PubMed

Vázquez-Costa, J F; Martínez-Molina, M; Fernández-Polo, M; Fornés-Ferrer, V; Frasquet-Carrera, M; Sevilla-Mantecón, T

2018-06-11

Amyotrophic lateral sclerosis (ALS) is an insidious, clinically heterogeneous neurodegenerative disease associated with a diagnostic delay of approximately 12 months. No study conducted to date has analysed the diagnostic pathway in Spain. We gathered data on variables related to the diagnostic pathway and delay for patients diagnosed with ALS between October 2013 and July 2017. The study included 143 patients with ALS (57% men; 68% spinal onset). Patients were diagnosed in public centres in 86% of cases and in private centres in 14%.The mean diagnostic delay was 13.1 months (median 11.7). Patients were examined by neurologists a mean time of 7.9 months after symptom onset, with diagnosis being made 5.2 months later. Half of all patients underwent unnecessary diagnostic tests and multiple electrophysiological studies before diagnosis was established. Diagnostic delay was longer in cases of spinal onset (P = .008) due to onset of the disease in the lower limbs. No differences were found between the public and private healthcare systems (P = .897). The diagnostic delay in ALS in Spain is similar to that of neighboring countries and seems to depend on disease-related factors, not on the healthcare system. Patients with lower-limb onset ALS constitute the greatest diagnostic challenge. Misdiagnosis is frequent, and partly attributable to an incorrect approach or erroneous interpretation of electrophysiological studies. Specific training programmes for neurologists and general neurophysiologists and early referral to reference centers may help to reduce diagnostic delay. Copyright © 2018 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

Tuberculosis mimicking lung cancer

PubMed Central

Hammen, I.

2015-01-01

Tuberculosis (TB) is well known as a diagnostic chameleon and can resemble malignancy. In thorax TB can be manifested as pulmonary infiltrates and/or mediastinal lymphadenopathy. In low incident countries with high incidence of lung cancer and varying clinical presentations, TB often gets misdiagnosed with the result of delayed treatment start and unnecessary diagnostic procedures. Our case report presents two patients, who were referred to the Thorax diagnostic centre at the Department of Respiratory Medicine, Odense University Hospital, with presumptive diagnosis of neoplasm and had proved lung TB with no evidence of malignancy instead. In the first case diagnosis was confirmed after thoracotomy, in the second case after bronchoscopy. PMID:26744652

PROMISE of Coronary CT Angiography: Precise and Accurate Diagnosis and Prognosis in Coronary Artery Disease.

PubMed

Thomas, Dustin M; Branch, Kelley R; Cury, Ricardo C

2016-04-01

Coronary computed tomography angiography (CCTA) is a rapidly growing and powerful diagnostic test that offers a great deal of precision with respect to diagnosing coronary artery disease (CAD). Guideline statements for patients with stable ischemic heart disease have recommended CCTA for only a limited portion of intermediate-risk patients who have relative or absolute contraindications for exercise or vasodilator stress testing. The publication of two large, prospective randomized clinical trials, the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial are likely to expand these indications. These new data from large trials, in addition to other studies, show that CCTA is highly sensitive for the detection of CAD, identifies high-risk patients for cardiac events based on extent or plaque morphology of CAD that would not be identified by other noninvasive means, and provides significantly greater diagnostic certainty for proper treatment, including referral for invasive coronary angiography with revascularization more appropriately. Superior diagnostic accuracy and prognostic data with CCTA, when compared with other functional stress tests, may result in a reduction in unnecessary downstream testing and cost savings. In addition, newer CCTA applications hold the promise of providing a complete evaluation of a patient's coronary anatomy as well as a per-vessel ischemic evaluation. This review focuses on the interval knowledge obtained from newer data on CCTA in patients with stable ischemic heart disease, primarily focusing on the contributions of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial.

Computer assisted axial tomography (Emi scan) in neurologic investigation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Campbell, J.K.; Baker, H.L.; Laws, E.R. Jr.

1974-01-01

Cerebral angiography, pneumoencephalography, and radioisotope brain scan with their differing diagnostic abilities have provided the neurologist and neurosurgeon with extremely valuable diagnostic techniques. It is doubtful, however, if any of these now conventional methods had the enormous impact on the practice of neurology that computer assisted axial tomography (C.A.T.) is beginning to have. Here, for the first time, is a test which, without significant risk or discomfort, can demonstrate some normal intracranial (and intraorbital) structures, can demonstrate some normal intracranial pathology and, in many cases, can make the potentially dangerous contrast studies unnecessary. After only a few months experience withmore » C.A.T. in a clinical setting, it has become obvious that there will have to be a reappraisal of the accepted investigative work-up of many conditions. While it is too early to have formulated strict criteria for the use of C.A.T., this paper is an attempt to show how the technique is proving useful in the investigation of many conditions.« less

Comparison of Various Methods in the Diagnosis of Entamoeba histolytica in Stool and Serum Specimens

PubMed Central

Uslu, Hakan; Aktas, Osman; Uyanik, Muhammet Hamidullah

2016-01-01

Objective: Entamoeba histolytica is indistinguishable from Entamoeba dispar in direct microscopic examination. A definitive diagnosis of E. histolytica is important in terms of the treatment of the patient and to avoid unnecessary costs. This study’s aim is to determine the prevalence of E. histolytica and to make a comparison of the different diagnostic tests in the patients specimens defined as E. histolytica/E. dispar infection. Materials and Methods: Faecal and serum specimens of 90 patients defined as E. histolytica/E. dispar with microscopy (wet mount examination with 0.85% saline and Lugol’s iodine) were examined. Stool samples were examined by trichrome staining for trophozoites and cysts and by immunoassay methods for specific adhesin antigens (Wampole ® E. histolytica II antigen testing) and for specific serine-rich 30 kD membrane protein (Serazym® E. histolytica antigen testing). Anti-E. histolytica antibodies were investigated using a latex slide test and indirect hemagglutination methods in serum specimens. Results: Presence of E. histolytica was not confirmed in 31.1% cases with trichrome staining, 62.2% of the Wampole antigen test, 64.4%, of the Serazym antigen test, 73.3% of the indirect hemagglutination test and 75.6%. of the latex agglutination. Considering the common results from Wampole and Serazym antigen testing as a reference standard, the specificity/sensitivity is 100/53.85% for trichrome staining, 75.00/98.11% for the latex agglutination test and 78.57/96.77% for the indirect hemagglutination test. Conclusion: It has been shown that investigation of E. histolytica in stools by direct wet-smear microscopy alone can cause significant false positive results. To obtain a reliable diagnosis for E. histolytica and to avoid unnecessary treatment for this parasite, at least one more specific assay, particularly an antigen testing and microscopy, is required. PMID:27551176

Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review.

PubMed

Boyce, Matthew R; O'Meara, Wendy P

2017-05-18

The World Health Organization recommends parasitological confirmation of malaria prior to treatment. Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques. Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care. Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts. This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools. A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa. Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included. Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa. The literature search identified 757 reports. A total of 52 studies were included in the analysis. Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training. Analogous information was largely absent for formal health care workers. Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed. Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results. Malaria RDTs are generally used well, though compliance with test results is variable - especially in the formal health care sector. If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use. Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool.

Dental pulp neurophysiology: part 2. Current diagnostic tests to assess pulp vitality.

PubMed

Abd-Elmeguid, Ashraf; Yu, Donald C

2009-03-01

In this second part of our 2-part review, we discuss recent research about pulp tests that determine the vitality of the tooth and clinically accepted pulp testers. A pain response to hot, cold or an electric pulp tester indicates the vitality of only a tooth's pulpal sensory supply; the response does not give any idea about the state of the pulp. Although the sensitivity of these tests is high, when false-positive and false-negative results occur, they may affect the treatment of the tooth. A tooth falsely diagnosed as nonvital with an electric pulp tester may undergo an unnecessary root canal, whereas one falsely diagnosed as vital may be left untreated, causing the necrotic tissue to destroy the supporting tissues (resorption). The vascular supply is more important to the determination of the health of the pulp than the sensory supply. Pulp death is caused by cessation of blood flow and may result in a necrotic pulp, even though the pulpal sensory supply may still be viable. The pulp can be healed only if the circulating blood flow is healthy. Although still under investigation, diagnostic devices that examine pulpal blood flow, such as the pulse oximeter and laser Doppler flowmetry, show promising results for the assessment of pulp vitality.

Re-evaluating the relationships among filtering activity, unnecessary storage, and visual working memory capacity.

PubMed

Emrich, Stephen M; Busseri, Michael A

2015-09-01

The amount of task-irrelevant information encoded in visual working memory (VWM), referred to as unnecessary storage, has been proposed as a potential mechanism underlying individual differences in VWM capacity. In addition, a number of studies have provided evidence for additional activity that initiates the filtering process originating in the frontal cortex and basal ganglia, and is therefore a crucial step in the link between unnecessary storage and VWM capacity. Here, we re-examine data from two prominent studies that identified unnecessary storage activity as a predictor of VWM capacity by directly testing the implied path model linking filtering-related activity, unnecessary storage, and VWM capacity. Across both studies, we found that unnecessary storage was not a significant predictor of individual differences in VWM capacity once activity associated with filtering was accounted for; instead, activity associated with filtering better explained variation in VWM capacity. These findings suggest that unnecessary storage is not a limiting factor in VWM performance, whereas neural activity associated with filtering may play a more central role in determining VWM performance that goes beyond preventing unnecessary storage.

Noninvasive Prenatal Genetic Testing: Current and Emerging Ethical, Legal, and Social Issues.

PubMed

Minear, Mollie A; Alessi, Stephanie; Allyse, Megan; Michie, Marsha; Chandrasekharan, Subhashini

2015-01-01

Noninvasive prenatal genetic testing (NIPT) for chromosomal aneuploidy involving the analysis of cell-free fetal DNA became commercially available in 2011. The low false-positive rate of NIPT, which reduces unnecessary prenatal invasive diagnostic procedures, has led to broad clinician and patient adoption. We discuss the ethical, legal, and social issues raised by rapid and global dissemination of NIPT. The number of women using NIPT is anticipated to expand, and the number of conditions being tested for will continue to increase as well, raising concerns about the routinization of testing and negative impacts on informed decision making. Ensuring that accurate and balanced information is available to all pregnant women and that access to NIPT is equitable will require policy guidance from regulators, professional societies, and payers. Empirical evidence about stakeholders' perspectives and experiences will continue to be essential in guiding policy development so that advances in NIPT can be used effectively and appropriately to improve prenatal care.

Towards a systematic nationwide screening strategy for MODY.

PubMed

Shields, Beverley; Colclough, Kevin

2017-04-01

MODY is an early-onset monogenic form of diabetes. Correctly identifying MODY is of considerable importance as diagnosing the specific genetic subtype can inform the optimal treatment, with many patients being able to discontinue unnecessary insulin treatment. Diagnostic molecular genetic testing to confirm MODY is expensive, so screening strategies are required to identify the most appropriate patients for testing. In this issue of Diabetologia, Johansson and colleagues (DOI 10.1007/s00125-016-4167-1 ) describe a nationwide systematic screening approach to identify individuals with MODY in the paediatric age range. They focused testing on patients negative for both GAD and islet antigen 2 (IA-2) islet autoantibodies, thereby ruling out those with markers of type 1 diabetes, the most common form of diabetes in this age group. This commentary discusses the advantages and limitations of the approach, and the caution required when interpreting variants of uncertain pathogenicity identified from testing whole populations rather than targeting only patients with a strong MODY phenotype.

Pediatrician's knowledge on the management of the infant who cries excessively in the first months of life

PubMed Central

Marcon, Ana Carolina C.; Vieira, Mário César; de Morais, Mauro Batista

2014-01-01

OBJECTIVE: To evaluate the attitude, the practice and the knowledge of pediatricians regarding the management of the infant who cries excessively in the first months of life. METHODS: Descriptive cross-sectional study that enrolled pediatricians (n=132) randomly interviewed at a Pediatric meeting in Brazil, in August 2012. The data were collected by a self-administered standardized form after reading the hypothetical case of an infant who cried excessively. RESULTS: The majority of the participants were females, the mean age was 39 years and the average mean time working in the specialty was 14 years; 52.2% were Board Certified by the Brazilian Society of Pediatrics. The diagnosis most often considered was gastroesophageal reflux disease (62.9%), followed by infant colic (23.5%) and cow's milk allergy (6.8%). The diagnostic test most frequently mentioned was 24-hour esophageal pH-monitoring (21.9%). The medications most frequently indicated were domperidone (30.3%), the combination of domperidone with ranitidine (12.1%) and paracetamol (6%). CONCLUSIONS: In the approach of the infant who cries excessively, diagnostic tests are frequently requested and unnecessary medical treatment is usually recommended. PMID:25119749

Duplicate laboratory test reduction using a clinical decision support tool.

PubMed

Procop, Gary W; Yerian, Lisa M; Wyllie, Robert; Harrison, A Marc; Kottke-Marchant, Kandice

2014-05-01

Duplicate laboratory tests that are unwarranted increase unnecessary phlebotomy, which contributes to iatrogenic anemia, decreased patient satisfaction, and increased health care costs. We employed a clinical decision support tool (CDST) to block unnecessary duplicate test orders during the computerized physician order entry (CPOE) process. We assessed laboratory cost savings after 2 years and searched for untoward patient events associated with this intervention. This CDST blocked 11,790 unnecessary duplicate test orders in these 2 years, which resulted in a cost savings of $183,586. There were no untoward effects reported associated with this intervention. The movement to CPOE affords real-time interaction between the laboratory and the physician through CDSTs that signal duplicate orders. These interactions save health care dollars and should also increase patient satisfaction and well-being.

[Diagnostic and therapeutic activity moderation. Quaternary and genetic prevention].

PubMed

Gérvas, Juan

2006-03-01

Medical activities have more positive than negative outcomes. Because this balance, medicine has a great social recognition. But with new technology and more aggressive diagnostic and therapeutic interventions, there is a decreasing gap in between benefits and harms. Risk increases because more interventions, and because placing patients in more technology environments. As a consecuence, patient safety decreases. Quantity becomes as important as quality, and the place of care is crucial for patient safety. Medical activities should be of , performed in the low level of care possible. Then, quaternary prevention (to avoid unnecessary use and risk of medical interventions) should be a continuous parallel clinical activity. I consider four examples of needed quaternary prevention, with Spanish data: 1) cardiovascular prevention (where there is an inverse use of resources, as patients who need more receive less); 2) use of new antidepressants (which has provoke an artificial epidemic of

The concordance of serial ANA tests in an Australian tertiary hospital pathology laboratory.

PubMed

Lee, Adrian Y S; Hudspeth, Andrew R; Adelstein, Stephen

2016-10-01

The antinuclear antibody (ANA) tests are some of the more frequently requested tests for the diagnosis of autoimmunity. Although they are used primarily as diagnostic blood tests, multiple requests on the same patient continue to be encountered in the laboratory. This retrospective analysis of serial ANA testing at one pathology laboratory in Australia is the first study that examines the statistical concordance and possible implications of this on clinical practice. High-titred ANA have quite good repeatability for titre and pattern, and low-titred ANA, which can be non-specific, have poor repeatability. Staining patterns are, in general, almost random in nature on serial tests when compared to the first-obtained ANA pattern for each patient. This study confirms that there is little benefit in serial ANA testing, and only if there is a clear change in the patient's clinical picture would repeat of an initial low-titred ANA be useful. The findings reinforce the need for pathology stewardship to minimise costs, wasted resources and unnecessary referrals. Copyright © 2016 Royal College of Pathologists of Australasia. All rights reserved.

Triple Test in Carcinoma Breast

PubMed Central

Sameer; Mukherjee, Arindam

2014-01-01

Introduction: The commonest clinical presentation in majority of breast pathology is a lump. A definite diagnosis of breast lump is very important for the surgeon to decide on the final course of treatment and also saves the patient from unnecessary physical, emotional and psychological trauma if there is a definite preoperative diagnosis of benign lesion. The present study was done to evaluate the effectiveness and relevance of “TRIPLE TEST”in diagnosis of carcinoma breast in rural labour class population. Materials and Methods: The present study was a prospective study conducted on patients over 35 years of age having palpable breast lumps presenting in the out patient department of general surgery, ESI Hospital Basaidarapur New Delhi, India. The duration of study was from May 2007 to June 2009 and a total of 100 cases were studied. Each patient was subjected to a detailed history, clinical breast examination ,diagnostic mammography and FNAC. In this study, the results of each modality was divided in three groups: benign, suspicious and malignant. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of each test was calculated individually and as combined. Result: Out of 100 patients enrolled in this study, 60 cases were benign and 40 cases were of malignant breast disease. The age of patients with carcinoma breast in the series varied from 35 years to 70 years. The highest incidence of malignancy noted was 30% in 41-50 years age group (4th decade) followed by 27.5% in 51-60 years age group (5th decade). The sensitivity of clinical examination was found to be 75%, specificity was 83.3%, positive predictive value (PPV) of 75% and diagnostic accuracy of 80%. The sensitivity, specificity, positive predictive value and diagnostic accuracy of mammography was calculated and was found to be 94.9% , 90% , 86% and 92% respectively. The sensitivity, specificity, positive predictive value and diagnostic accuracy of FNAC was 94.7%, 98.3%, 97.3% and 96.6% respectively. Out of 100 cases triple test was concordant (all three test either benign or malignant) in 80 cases, all the benign cases detected by triple test were benign on final biopsy i.e. 100% specificity and 100% negative predictive value. Conclusion: TTS is an accurate and least invasive diagnostic test based on which definitive treatment can be initiated. PMID:25478391

Tuberculosis and the pancreas: a diagnostic challenge solved by endoscopic ultrasound. A case series.

PubMed

Chatterjee, Suvadip; Schmid, Matthias L; Anderson, Kirsty; Oppong, Kofi W

2012-03-01

Pancreatic tuberculosis is a rare disease. It can be easily confused with malignancy or pancreatitis on imaging. This could result in unnecessary surgery. As this is a treatable disease it is imperative to diagnose this condition pre-operatively. We report three cases of pancreatic tuberculosis that were diagnosed by endoscopic ultrasound. In conclusion, endoscopic ultrasound is the diagnostic modality of choice for pancreatic tuberculosis facilitating high resolution imaging, as well as sampling of tissue for staining, cytology, culture and polymerase chain reaction assay.

Complications of hematopoietic stem transplantation: Fungal infections.

PubMed

Omrani, Ali S; Almaghrabi, Reem S

2017-12-01

Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk of invasive fungal infections, especially during the early neutropenic phase and severe graft-versus-host disease. Mold-active prophylaxis should be limited to the highest risk groups. Empiric antifungal therapy for HSCT with persistent febrile neutropenia is associated with unacceptable response rates, unnecessary antifungal therapy, increased risk of toxicity, and inflated costs. Empiric therapy should not be a substitute for detailed work up to identify the cause of fever in such patients. The improved diagnostic performance of serum biomarkers such as galactomannan and β-D-glucan, as well as polymerase chain reaction assays has allowed the development of diagnostic-driven antifungal therapy strategies for high risk patients. Diagnostic-driven approaches have resulted in reduced unnecessary antifungal exposure, improved diagnosis of invasive fungal disease, and reduced costs without increased risk of mortality. The appropriateness of diagnostic-driven antifungal strategy for individual HSCT centers depends on the availability and turnaround times for diagnostics, multidisciplinary expertise, and the local epidemiology of invasive fungal infections. Echinocandins are the treatment of choice for invasive candidiasis in most HSCT recipients. Fluconazole may be used for the treatment of invasive candidiasis in hemodynamically stable patients with no prior azole exposure. The primary treatment of choice for invasive aspergillosis is voriconazole. Alternatives include isavuconazole and lipid formulations of amphotericin. Currently available evidence does not support routine primary combination antifungal therapy for invasive aspergillosis. However, combination salvage antifungal therapy may be considered in selected patients. Therapeutic drug monitoring is recommended for the majority of HSCT recipients on itraconazole, posaconazole, or voriconazole. Copyright © 2017 King Faisal Specialist Hospital & Research Centre. Published by Elsevier B.V. All rights reserved.

Diagnostics in assisted human reproduction.

PubMed

Montoya, Juan Manuel; Bernal, Alejandra; Borrero, Claudia

2002-01-01

The World Health Organization (WHO) estimates that 50-80 x 10(6) couples in the world are infertile, i.e. 7-15% of all couples of reproductive age (15-45 years old). The term infertility refers to couples who have been unable to conceive children for at least 1 year of regular unprotected intercourse. Although the frequency and origin of infertility varies, approximately 40-60% of the aetiology of infertility in the population studied is due to female causes. The introduction of assisted reproduction techniques, which offer couples the best opportunities for pregnancy, has opened a vast field of knowledge in reproductive biology. The medical history must be taken meticulously, with enough time to obtain the largest possible amount of relevant information. It is recommended that both partners be included in the initial work-up. In recent decades, technological progress has been favoured with the development of a great variety of diagnostic tests. Moreover, a very valuable tool helping to solve this problem has gained strength and is available to everybody - so-called 'evidence-based medicine'. There are three categories in infertility diagnostic tests. The first category includes tests showing a well-established correlation with pregnancy, e.g. semen analysis, tubal patency with hysterosalpingography or laparoscopy, and ovulation detection. The second category includes patients whose results are not consistently related to pregnancy. Here, these tests include sperm penetration assay in the zona-free hamster oocyte, post-coital tests, sperm penetration into cervical mucus, and tests to detect anti-sperm antibodies. The third group includes patients whose tests are not correlated with pregnancy. The relevant tests include endometrial biopsy, the presence of varicocele, and Chlamydia detection tests. Tests for infertility are often expensive. Since these patients are usually anxious and eager and will do almost anything to have a child, care must be taken to avoid exploitation of their hopes with unnecessary procedures. This text now reviews and updates the procedures used to investigate infertility.

The Case for Intervention Bias in the Practice of Medicine

PubMed Central

Foy, Andrew J.; Filippone, Edward J.

2013-01-01

Bias is an inclination to present or hold a partial perspective at the expense of possibly equal or more valid alternatives. In this paper, we present a series of conditional arguments to prove that intervention bias exists in the practice of medicine. We then explore its potential causes, consequences, and criticisms. We use the term to describe the bias on the part of physicians and the medical community to intervene, whether it is with drugs, diagnostic tests, non-invasive procedures, or surgeries, when not intervening would be a reasonable alternative. The recognition of intervention bias in medicine is critically important given today’s emphasis on providing high-value care and reducing unnecessary and potentially harmful interventions. PMID:23766747

Management of Postoperative Fever in Adult Cardiac Surgical Patients.

PubMed

O'Mara, Susan K

Postoperative fever after cardiac surgery is a common occurrence. Most fevers are benign and self-limiting resulting from inflammation caused by surgical trauma and blood contact with cardiopulmonary bypass circuit resulting in the release of cytokines. Only a small percentage of time is postoperative fever due to an infection complicating surgery. The presence of fever frequently triggers a battery of diagnostic tests that are costly, could expose the patient to unnecessary risks, and can produce misleading or inconclusive results. It is therefore important that fever be evaluated in a systematic, prudent, clinically appropriate, and cost-effective manner. This article focuses on the current evidence regarding pathophysiology, incidence, causes, evaluation, and management of fever in postoperative adult cardiac surgical patients.

Repeat haematinic requests in patients with previous normal results: the scale of the problem in elderly patients at a district general hospital.

PubMed

Ganiyu-Dada, Z; Bowcock, S

2011-12-01

Repeating normal laboratory tests can waste resources. This study aimed to quantify unnecessary repeat haematinic tests taken from the elderly in a district general hospital. Haematinic tests (ferritin, B12, serum folate) from patients age ≥ 70 years were reviewed for repeat tests during an 8-week period. Questionnaires were given to doctors to establish when the considered repeating a 'borderline low normal' result to be clinically justifiable. 7.7% of all haematinic tests were repeat tests and of these, the majority (83%) was performed following a previously normal result. Thirteen of 24 doctors believed repeating a normal result at the bottom of the normal range ('borderline low normal') was justifiable. After excluding 'borderline low normal' results, 6.0% (at minimum) of repeat tests were done following a previous normal result and were unnecessary. This audit showed that there are a significant number of unnecessary repeat haematinic tests being performed. © 2011 Blackwell Publishing Ltd.

Magnetic Resonance Imaging as an Adjunct to Mammography for Breast Cancer Screening in Women at Less Than High Risk for Breast Cancer: A Health Technology Assessment

PubMed Central

Nikitovic-Jokic, Milica; Holubowich, Corinne

2016-01-01

Background Screening with mammography can detect breast cancer early, before clinical symptoms appear. Some cancers, however, are not captured with mammography screening alone. Among women at high risk for breast cancer, magnetic resonance imaging (MRI) has been suggested as a safe adjunct (supplemental) screening tool that can detect breast cancers missed on screening mammography, potentially reducing the number of deaths associated with the disease. However, the use of adjunct screening tests may also increase the number of false-positive test results, which may lead to unnecessary follow-up testing, as well as patient stress and anxiety. We investigated the benefits and harms of MRI as an adjunct to mammography compared with mammography alone for screening women at less than high risk (average or higher than average risk) for breast cancer. Methods We searched Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Centre for Reviews and Dissemination (CRD) Health Technology Assessment Database, and National Health Service (NHS) Economic Evaluation Database, from January 2002 to January 2016, for evidence of effectiveness, harms, and diagnostic accuracy. Only studies evaluating the use of screening breast MRI as an adjunct to mammography in the specified populations were included. Results No studies in women at less than high risk for breast cancer met our inclusion criteria. Conclusions It remains uncertain if the use of adjunct screening breast MRI in women at less than high risk (average or higher than average risk) for breast cancer will reduce breast cancer–related mortality without significant increases in unnecessary follow-up testing and treatment. PMID:27990198

Delving into cornerstones of hypersensitivity to antineoplastic and biological agents: value of diagnostic tools prior to desensitization.

PubMed

Alvarez-Cuesta, E; Madrigal-Burgaleta, R; Angel-Pereira, D; Ureña-Tavera, A; Zamora-Verduga, M; Lopez-Gonzalez, P; Berges-Gimeno, M P

2015-07-01

Evidence regarding drug provocation test (DPT) with antineoplastic and biological agents is scarce. Our aim was to assess the usefulness of including DPT as a paramount gold standard diagnostic tool (prior to desensitization). Prospective, observational, longitudinal study with patients who, during a 3-year period, were referred to the Desensitization Program at Ramon y Cajal University Hospital. Patients underwent a structured diagnostic protocol by means of anamnesis, skin tests (ST), risk assessment, and DPT. Oxaliplatin-specific IgE was determined in oxaliplatin-reactive patients (who underwent DPT regardless of oxaliplatin-specific IgE results). Univariate analysis and multivariate analysis were used to identify predictors of the final diagnosis among several variables. A total of 186 patients were assessed. A total of 104 (56%) patients underwent DPT. Sixty-four percent of all DPTs were negative (i.e., hypersensitivity was excluded). Sensitivity for oxaliplatin-specific IgE (0.35 UI/l cutoff point) was 34%, specificity 90.3%, negative predictive value 45.9%, positive predictive value 85%, negative likelihood ratio 0.7, and positive likelihood ratio 3.5. These are the first reported data based on more than 100 DPTs with antineoplastic and biological agents (paclitaxel, oxaliplatin, rituximab, infliximab, irinotecan, and other drugs). Implementation of DPT in diagnostic protocols helps exclude hypersensitivity (in 36% of all referred patients), and avoids unnecessary desensitizations in nonhypersensitive patients (30-56% of patients, depending on culprit-drug). Drug provocation test is vital to validate diagnostic tools; consequently, quality data are shown on oxaliplatin-specific IgE and oxaliplatin-ST in the largest series of oxaliplatin-reactive patients reported to date (74 oxaliplatin-reactive patients). Identifying phenotypes and predictors of a diagnosis of hypersensitivity may be helpful for tailored plans. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Case Report: Diagnosis of a Rare Plaque-Like Dermal Fibroma Successfully Treated With Mohs Surgery.

PubMed

Gill, Pavandeep; Arlette, John; Shiau, Carolyn J; Abi Daoud, Marie S

CD34-positive plaque-like dermal fibroma (PDF) is a poorly characterised benign dermal neoplasm that has a wide differential diagnosis. It can be mistaken for other entities on superficial biopsy and be overtreated, leading to unnecessary worry and extensive surgery. To report on an uncommon presentation of this entity, the histopathologic differential diagnosis of PDF, and a novel treatment method. Clinical and histopathological information was obtained for a PDF lesion on a 75-year-old man. On superficial biopsy, the PDF lesion was misinterpreted as a possible neurothekeoma. Successful Mohs surgery and genetic testing confirmed the diagnosis of PDF, and the patient received appropriate tissue-sparing surgical management. This case adds to our current knowledge about PDF and highlights the importance of early recognition of these lesions to direct appropriate diagnostic testing (full-thickness biopsy) and management. This case confirms successful management with Mohs surgery.

Cerebrospinal fluid myelin basic protein is frequently ordered but has little value: a test utilization study.

PubMed

Greene, Dina N; Schmidt, Robert L; Wilson, Andrew R; Freedman, Mark S; Grenache, David G

2012-08-01

Diagnosis of multiple sclerosis (MS) is facilitated by analyzing biochemical properties of cerebrospinal fluid (CSF). Oligoclonal bands (OCBs) and immunoglobulin G (IgG) index are well-established markers for evaluating patients suspected of having MS. Myelin basic protein (MBP) is also ordered frequently, but its usefulness remains questionable. OCB, IgG index, and MBP were measured in 16,690 consecutive CSF samples. Samples were divided into 2 groups based on MS status known (n = 71) or unknown (n = 16,118). Medical charts of the MS status known group were reviewed to determine their MS status. OCBs have a stronger association to IgG index results than does MBP. Importantly, MBP does not add a statistically significant increase in diagnostic sensitivity or specificity when used in combination with OCB and/or IgG index. The data indicate that MBP is an unnecessary and overused test.

Perceptions of Emergency Medicine Residency and Hand Surgery Fellowship Program Directors in the Appropriate Disposition of Upper Extremity Emergencies.

PubMed

Drolet, Brian C; Lifchez, Scott D; Jacoby, Sidney M; Varone, Andrew; Regan, Linda A; Baren, Jill M; Akelman, Edward; Osterman, A Lee; Levin, L Scott

2015-12-01

To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background--EM, general orthopedic or plastic surgery, or hand fellowship--most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. Economic and Decision Analyses IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Necrotizing lymphadenitis: If not tuberculosis then what?

PubMed Central

Punjabi, Rhea K.

2018-01-01

We present a rare case of Kikuchi disease in a young lady presenting with fever and cervical lymphadenopathy. Clinically, the disease mimics tuberculosis and lymphoma. Lymph node biopsy is diagnostic and treatment is symptomatic. Although tuberculosis is endemic, clinicians should be aware of uncommon conditions as early recognition of the disease will minimize unnecessary evaluation and treatment. PMID:29915771

Necrotizing lymphadenitis: If not tuberculosis then what?

PubMed

Punjabi, Rhea K

2018-01-01

We present a rare case of Kikuchi disease in a young lady presenting with fever and cervical lymphadenopathy. Clinically, the disease mimics tuberculosis and lymphoma. Lymph node biopsy is diagnostic and treatment is symptomatic. Although tuberculosis is endemic, clinicians should be aware of uncommon conditions as early recognition of the disease will minimize unnecessary evaluation and treatment.

Role of 3D power Doppler ultrasound in the further characterization of suspicious breast masses.

PubMed

Kupeli, Ali; Kul, Sibel; Eyuboglu, Ilker; Oguz, Sukru; Mungan, Sevdegul

2016-01-01

To investigate effectiveness of vascular indices obtained with 3D power Doppler ultrasound in the further characterization of breast masses and prevention of unnecessary biopsies. Between April 2013 and March 2014, 109 patients (age range, 17-85 years; mean age, 47 years) with 117 radiologically or clinically suspicious breast masses were prospectively evaluated with 3DPDUS before biopsy. Mass volume (MV), vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using Virtual Organ Computer-aided Analysis (VOCAL) software and they were correlated with the final diagnosis. Cutoff values of vascular indices were determinated and diagnostic efficacy was calculated with receiver operating curve (ROC) analysis. All vascular indices, age of patients and tumor volume were significantly lower in benign masses compared with malignant ones (p<0.001). AUCs were 0.872, 0.867 and 0.789 for VI, VFI and FI, respectively. The diagnostic efficacy of VI (for cutoff 1.1; 83% sensitivity, 82% specificity and 82% accuracy) and VFI (for cutoff 0.4; 80% sensitivity, 83% specificity and 80% accuracy) were significantly higher than FI (for cutoff 33,9; 73% sensitivity, 69% specificity and 71% accuracy). It was found that with the use of vascular indices of 3DPDUS in the further characterization of suspicious breast masses between 24% to 37% of unnecessary biopsies could have been avoided. The vascular indices obtained with 3DPDUS seem reliable in the further characterization of suspicious breast masses and might be used to decrease unnecessary biopsies. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Healthcare Transformation and Changing Roles for Nursing

PubMed Central

Salmond, Susan W.; Echevarria, Mercedes

2017-01-01

Factors driving healthcare transformation include fragmentation, access problems, unsustainable costs, suboptimal outcomes, and disparities. Cost and quality concerns along with changing social and disease-type demographics created the greatest urgency for the need for change. Caring for and paying for medical treatments for patients suffering from chronic health conditions are a significant concern. The Affordable Care Act includes programs now led by the Centers for Medicare & Medicaid Services aiming to improve quality and control cost. Greater coordination of care—across providers and across settings—will improve quality care, improve outcomes, and reduce spending, especially attributed to unnecessary hospitalization, unnecessary emergency department utilization, repeated diagnostic testing, repeated medical histories, multiple prescriptions, and adverse drug interactions. As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. Nurses are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team as we shift from episodic, provider-based, fee-for-service care to team-based, patient-centered care across the continuum that provides seamless, affordable, and quality care. These shifts require a new or an enhanced set of knowledge, skills, and attitudes around wellness and population care with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement. PMID:28107295

DNA methylation based testing of 418 patients suspected of having Prader-Willi syndrome (PWS) and tentative localization of the 15q11-13 imprinting center

DOE Office of Scientific and Technical Information (OSTI.GOV)

Horsthemke, B.; Dittrich, B.; Buiting, K.

Using a test based on parent-of-origin specific DNA methylation at the D15S63 (PW71) locus, we studied 358 patients (aged 1-33 years) for diagnostic confirmation of PWS and 60 infants (aged 0-12 months) with severe hypotonia of unknown origin. 57/358 patients were examined personally. 28/57 patients showed typical clinical signs of PWS and lacked the paternal PW71 band. 29-57 patients did not fulfill the diagnostic criteria for PWS and had a normal methylation pattern. This suggests that the test detects most if not all patients with typical PWS. 301/358 samples were sent to us from outside. The test confirmed the diagnosismore » in 105/301 patients. Most of the other 196 patients lacked neonatal hypotonia and hypogonadism. On the other hand, 27/60 hypotonic infants tested positive for PWS. These results indicate that PWS is often not recognized in infants and wrongly diagnosed in obese children and adults. We propose to perform the PW71 methylation test in every newborn with severe hypotonia of unknown origin to avoid unnecessary diagnostic procedures. In the course of diagnostic testing we and others have identified PWS and Angelman syndrome (AS) patients with apparently normal chromosomes of biparental inheritance, but abnormal DNA methylation and gene expression. The identification of microdeletions in some of these patients suggests the existence of an imprinting center within 30 kb proximal of SNRPN, which regulates the chromatin structure, DNA methylation and gene expression. We propose that the paternal copy of 15q11-13 has a euchromatoid structure, from which the PWS genes are transcribed, and that the maternal copy has a heterochromatoid structure from which the AS gene is transcribed. Depending on the parental origin of the mutation, both chromosomes of a patient have a heterochromatoid domain, which silences the PWS genes, or a euchromatoid domain, which silences the AS gene.« less

Bicentric evaluation of six anti-toxoplasma immunoglobulin G (IgG) automated immunoassays and comparison to the Toxo II IgG Western blot.

PubMed

Maudry, Arnaud; Chene, Gautier; Chatelain, Rémi; Patural, Hugues; Bellete, Bahrie; Tisseur, Bernard; Hafid, Jamal; Raberin, Hélène; Beretta, Sophie; Sung, Roger Tran Manh; Belot, Georges; Flori, Pierre

2009-09-01

A comparative study of the Toxoplasma IgG(I) and IgG(II) Access (Access I and II, respectively; Beckman Coulter Inc.), AxSYM Toxo IgG (AxSYM; Abbott Diagnostics), Vidas Toxo IgG (Vidas; bioMerieux, Marcy l'Etoile, France), Immulite Toxo IgG (Immulite; Siemens Healthcare Diagnostics Inc.), and Modular Toxo IgG (Modular; Roche Diagnostics, Basel, Switzerland) tests was done with 406 consecutive serum samples. The Toxo II IgG Western blot (LDBio, Lyon, France) was used as a reference technique in the case of intertechnique discordance. Of the 406 serum samples tested, the results for 35 were discordant by the different techniques. Using the 175 serum samples with positive results, we evaluated the standardization of the titrations obtained (in IU/ml); the medians (second quartiles) obtained were 9.1 IU/ml for the AxSYM test, 21 IU/ml for the Access I test, 25.7 IU/ml for the Access II test, 32 IU/ml for the Vidas test, 34.6 IU/ml for the Immulite test, and 248 IU/ml for the Modular test. For all the immunoassays tested, the following relative sensitivity and specificity values were found: 89.7 to 100% for the Access II test, 89.7 to 99.6% for the Immulite test, 90.2 to 99.6% for the AxSYM test, 91.4 to 99.6% for the Vidas test, 94.8 to 99.6% for the Access I test, and 98.3 to 98.7% for the Modular test. Among the 406 serum samples, we did not find any false-positive values by two different tests for the same serum sample. Except for the Modular test, which prioritized sensitivity, it appears that the positive cutoff values suggested by the pharmaceutical companies are very high (either for economical or for safety reasons). This led to imperfect sensitivity, a large number of unnecessary serological follow-ups of pregnant women, and difficulty in determining the serological status of immunosuppressed individuals.

Does prevalence matter to physicians in estimating post-test probability of disease? A randomized trial.

PubMed

Agoritsas, Thomas; Courvoisier, Delphine S; Combescure, Christophe; Deom, Marie; Perneger, Thomas V

2011-04-01

The probability of a disease following a diagnostic test depends on the sensitivity and specificity of the test, but also on the prevalence of the disease in the population of interest (or pre-test probability). How physicians use this information is not well known. To assess whether physicians correctly estimate post-test probability according to various levels of prevalence and explore this skill across respondent groups. Randomized trial. Population-based sample of 1,361 physicians of all clinical specialties. We described a scenario of a highly accurate screening test (sensitivity 99% and specificity 99%) in which we randomly manipulated the prevalence of the disease (1%, 2%, 10%, 25%, 95%, or no information). We asked physicians to estimate the probability of disease following a positive test (categorized as <60%, 60-79%, 80-94%, 95-99.9%, and >99.9%). Each answer was correct for a different version of the scenario, and no answer was possible in the "no information" scenario. We estimated the proportion of physicians proficient in assessing post-test probability as the proportion of correct answers beyond the distribution of answers attributable to guessing. Most respondents in each of the six groups (67%-82%) selected a post-test probability of 95-99.9%, regardless of the prevalence of disease and even when no information on prevalence was provided. This answer was correct only for a prevalence of 25%. We estimated that 9.1% (95% CI 6.0-14.0) of respondents knew how to assess correctly the post-test probability. This proportion did not vary with clinical experience or practice setting. Most physicians do not take into account the prevalence of disease when interpreting a positive test result. This may cause unnecessary testing and diagnostic errors.

[Managment of acute low back pain without trauma - an algorithm].

PubMed

Melcher, Carolin; Wegener, Bernd; Jansson, Volkmar; Mutschler, Wolf; Kanz, Karl-Georg; Birkenmaier, Christof

2018-05-14

Low back pain is a common problem for primary care providers, outpatient clinics and A&E departments. The predominant symptoms are those of so-called "unspecific back pain", but serious pathologies can be concealed by the clinical signs. Especially less experienced colleagues have problems in treating these patients, as - despite the multitude of recommendations and guidelines - there is no generally accepted algorithm. After a literature search (Medline/Cochrane), 158 articles were selected from 15,000 papers and classified according to their level of evidence. These were attuned to the clinical guidelines of the orthopaedic and pain-physician associations in Europe, North America and overseas and the experience of specialists at LMU Munich, in order to achieve consistency with literature recommendations, as well as feasibility in everyday clinical work and optimised with practical relevance. An algorithm was formed to provide the crucial differential diagnosis of lumbar back pain according to its clinical relevance and to provide a plan of action offering reasonable diagnostic and therapeutic steps. As a consequence of distinct binary decisions, low back patients should be treated at any given time according to the guidelines, with emergencies detected, unnecessary diagnostic testing and interventions averted and reasonable treatment initiated pursuant to the underlying pathology. In the context of the available evidence, a clinical algorithm has been developed that translates the complex diagnostic testing of acute low back pain into a transparent, structured and systematic guideline. Georg Thieme Verlag KG Stuttgart · New York.

[The drawbacks of diagnostic diligence].

PubMed

Giard, R W; Coebergh, J W

1998-10-03

More, earlier and better diagnostic work is being done nowadays, leasing to detection of abnormalities and preliminary stages that used to remain undetected; a large reservoir of subclinical disorders is found to exist. More intensive and sensitive diagnostic methods as a rule lead to higher disease prevalence figures, with the consequences of a seeming increase of disease risk, unnecessary further examinations, treatment and follow-up of individuals and overestimation of the effects of treatment. This may even start a vicious circle. More attention should be given to using diagnostic methods in such a way that the earlier and more frequent detection of disease actually profits the patient. The proof of this should be found in scientific (population) studies of the magnitude and severity of the burden of disease, the determinants of progression, the severity of abnormalities and diseases and the favourable effect of (early) treatment.

Physician responsibility for the cost of unnecessary medical services.

PubMed

Eisenberg, J M; Rosoff, A J

1978-07-13

Most diagnostic and therapeutic services are ordered by physicians, but physicians practicing under fee-for-service conditions have few incentives to contain the costs of medical care. Without such incentives, effective cost control through mechanisms such as Professional Standards Review Organizations have been disappointing. Several legal approaches might be used to increase physicians' responsibility for the cost of unnecessary services--expansion of tort law, implied contact, redesign of insurance mechanisms, equitable estoppel and informed consent. However, increasing physician responsibility will require uniform but flexible definitions of medical necessity, reliable means for predeterming the need for services and effective penalties or incentives. We propose a peer-review system that would incorporate the sharing of financial risk among physician, hospital, insurer and patient in the fee-for-service sector.

Laboratory Diagnosis of Human Rabies: Recent Advances

PubMed Central

Mani, Reeta Subramaniam; Madhusudana, Shampur Narayan

2013-01-01

Rabies, an acute progressive, fatal encephalomyelitis, transmitted most commonly through the bite of a rabid animal, is responsible for an estimated 61,000 human deaths worldwide. The true disease burden and public health impact due to rabies remain underestimated due to lack of sensitive laboratory diagnostic methods. Rapid diagnosis of rabies can help initiate prompt infection control and public health measures, obviate the need for unnecessary treatment/medical tests, and assist in timely administration of pre- or postexposure prophylactic vaccination to family members and medical staff. Antemortem diagnosis of human rabies provides an impetus for clinicians to attempt experimental therapeutic approaches in some patients, especially after the reported survival of a few cases of human rabies. Traditional methods for antemortem and postmortem rabies diagnosis have several limitations. Recent advances in technology have led to the improvement or development of several diagnostic assays which include methods for rabies viral antigen and antibody detection and assays for viral nucleic acid detection and identification of specific biomarkers. These assays which complement traditional methods have the potential to revolutionize rabies diagnosis in future. PMID:24348170

Molecular Signature of Indeterminate Thyroid Lesions: Current Methods to Improve Fine Needle Aspiration Cytology (FNAC) Diagnosis

PubMed Central

Cantara, Silvia; Marzocchi, Carlotta; Pilli, Tania; Cardinale, Sandro; Forleo, Raffaella; Castagna, Maria Grazia; Pacini, Furio

2017-01-01

Fine needle aspiration cytology (FNAC) represents the gold standard for determining the nature of thyroid nodules. It is a reliable method with good sensitivity and specificity. However, indeterminate lesions remain a diagnostic challenge and researchers have contributed molecular markers to search for in cytological material to refine FNAC diagnosis and avoid unnecessary surgeries. Nowadays, several “home-made” methods as well as commercial tests are available to investigate the molecular signature of an aspirate. Moreover, other markers (i.e., microRNA, and circulating tumor cells) have been proposed to discriminate benign from malignant thyroid lesions. Here, we review the literature and provide data from our laboratory on mutational analysis of FNAC material and circulating microRNA expression obtained in the last 6 years. PMID:28383480

Use of multiplex PCR based molecular diagnostics in diagnosis of suspected CNS infections in tertiary care setting-A retrospective study.

PubMed

Javali, Mahendra; Acharya, Purushottam; Mehta, Aneesh; John, Aju Abraham; Mahale, Rohan; Srinivasa, R

2017-10-01

CNS infections like meningitis and encephalitis pose enormous healthcare challenges due to mortality, sequelae and socioeconomic burden. In tertiary setting, clinical, microbiological, cytological and radiological investigations are not distinctive enough for diagnosing microbial etiology. Molecular diagnostics is filling this gap. We evaluated the clinical impact of a commercially available multiplex molecular diagnostic system - SES for diagnosing suspected CNS infections. This study was conducted in our tertiary level Neurology ICU. 110 patients admitted during Nov-2010 to April-2014 were included. CSF samples of patients clinically suspected of having CNS infections were subjected to routine investigation in our laboratory and SES test at XCyton Diagnostics. We studied the impact of SES in diagnosis of CNS infections and its efficacy in helping therapeutic management. SES showed detection rate of 42.18% and clinical specificity of 100%. It had 10 times higher detection rate than conventional tests. Streptococcus pneumoniae and Mycobacterium tuberculosis were two top bacterial pathogens. VZV was most detected viral pathogen. SES results elicited changes in therapy in both positive and negative cases. We observed superior patient outcomes as measured by GCS scale. 75% and 82.14% of the patients positive and negative on SES respectively, recovered fully. Detecting causative organism and ruling out infectious etiology remain the most critical aspect for management and prognosis of patients with suspected CNS infections. In this study, we observed higher detection rate of pathogens, target specific escalation and evidence based de-escalation of antimicrobials using SES. Institution of appropriate therapy helped reduce unnecessary use of antimicrobials. Copyright © 2017 Elsevier B.V. All rights reserved.

Who decides and what are people willing-to-pay for whole genome sequencing information?

PubMed Central

Marshall, DA; Gonzalez, JM; Johnson, FR; MacDonald, KV; Pugh, A; Douglas, MP; Phillips, KA

2016-01-01

PURPOSE Whole genome sequencing (WGS) can be used as a powerful diagnostic tool which could also be used for screening but may generate anxiety, unnecessary testing and overtreatment. Current guidelines suggest reporting clinically actionable secondary findings when diagnostic testing is performed. We estimated preferences for receiving WGS results. METHODS A US nationally representative survey (n=410 adults) was used to rank preferences for who decides (expert panel, your doctor, you) which WGS results are reported. We estimated the value of information about variants with varying levels of clinical usefulness using willingness-to-pay contingent valuation questions. RESULTS 43% preferred to decide themselves what information is included in the WGS report. 38% (95% CI:33–43%) would not pay for actionable variants, and 3% (95% CI:1–5%) would pay more than $1000. 55% (95% CI:50–60%) would not pay for variants in which medical treatment is currently unclear, and 7% (95% CI:5–9%) would pay more than $400. CONCLUSION Most people prefer to decide what WGS results are reported. Despite valuing actionable information more, some respondents perceive that genetic information could negatively impact them. Preference heterogeneity for WGS information should be considered in the development of policies, particularly to integrate patient preferences with personalized medicine and shared decision making. PMID:27253734

Diagnostic Accuracy of Copeptin in the Differential Diagnosis of the Polyuria-polydipsia Syndrome: A Prospective Multicenter Study.

PubMed

Timper, Katharina; Fenske, Wiebke; Kühn, Felix; Frech, Nica; Arici, Birsen; Rutishauser, Jonas; Kopp, Peter; Allolio, Bruno; Stettler, Christoph; Müller, Beat; Katan, Mira; Christ-Crain, Mirjam

2015-06-01

The polyuria-polydipsia syndrome comprises primary polydipsia (PP) and central and nephrogenic diabetes insipidus (DI). Correctly discriminating these entities is mandatory, given that inadequate treatment causes serious complications. The diagnostic "gold standard" is the water deprivation test with assessment of arginine vasopressin (AVP) activity. However, test interpretation and AVP measurement are challenging. The objective was to evaluate the accuracy of copeptin, a stable peptide stoichiometrically cosecreted with AVP, in the differential diagnosis of polyuria-polydipsia syndrome. This was a prospective multicenter observational cohort study from four Swiss or German tertiary referral centers of adults >18 years old with the history of polyuria and polydipsia. A standardized combined water deprivation/3% saline infusion test was performed and terminated when serum sodium exceeded 147 mmol/L. Circulating copeptin and AVP levels were measured regularly throughout the test. Final diagnosis was based on the water deprivation/saline infusion test results, clinical information, and the treatment response. Fifty-five patients were enrolled (11 with complete central DI, 16 with partial central DI, 18 with PP, and 10 with nephrogenic DI). Without prior thirsting, a single baseline copeptin level >21.4 pmol/L differentiated nephrogenic DI from other etiologies with a 100% sensitivity and specificity, rendering a water deprivation testing unnecessary in such cases. A stimulated copeptin >4.9 pmol/L (at sodium levels >147 mmol/L) differentiated between patients with PP and patients with partial central DI with a 94.0% specificity and a 94.4% sensitivity. A stimulated AVP >1.8 pg/mL differentiated between the same categories with a 93.0% specificity and a 83.0% sensitivity. This study was limited by incorporation bias from including AVP levels as a diagnostic criterion. Copeptin is a promising new tool in the differential diagnosis of the polyuria-polydipsia syndrome, and a valid surrogate marker for AVP. Primary Funding Sources: Swiss National Science Foundation, University of Basel.

Fracture diagnostics, unnecessary travel and treatment: a comparative study before and after the introduction of teleradiology in a remote general practice.

PubMed

Jacobs, Jac J W M; Jacobs, Jan P A M; van Sonderen, Eric; van der Molen, Thys; Sanderman, Robbert

2015-05-06

Teleradiology entails attainment of x-rays in one location, transfer over some distance and assessment at another location for diagnosis or consultation. This study documents fracture diagnostics, unnecessary trips to the hospital, treatment and number of x-rays for the years 2006 and 2009, before and after the introduction of teleradiology in a general practice on the island of Ameland in the north of the Netherlands. In a retrospective, descriptive, observational before and after study of the introduction of x-ray facilities in an island-based general practice, we compared the number of accurately diagnosed fractures, unnecessary trips, treatments and number of x-rays taken in 2006 when only a hospital x-ray facility was available 5 hours away with those in 2009 after an x-ray facility became available at a local general practice. All patients visiting a general practice on the island of Ameland in 2006 and 2009 with trauma and clinical suspicion of a fracture, dislocation or sprain were included in the study. The initial clinical diagnoses, including those based on the outcomes of x-rays, were compared for the two years and also whether the patients were treated at home or in hospital. A total of 316 and 490 patients with trauma visited a general practice in 2006 and 2009, respectively. Of these patients, 66 and 116 were found to have fractures or dislocations in the two years, respectively. In 2006, 83 x-rays were ordered; in 2009, this was 284. In 2006, 9 fractures were missed; in 2009, this was only 2. In 2006, 15 patients with fractures or dislocations were treated at the general practice; in 2009, this had increased to 77. Since the introduction of teleradiology the number of missed fractures in patients visiting the general practice with trauma and the number of the unnecessary trips to a hospital are reduced. In addition more patients with fractures and dislocations can be treated in the general practice as opposed to the hospital.

Diagnostic accuracy of contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging of small renal masses in real practice: sensitivity and specificity according to subjective radiologic interpretation.

PubMed

Kim, Jae Heon; Sun, Hwa Yeon; Hwang, Jiyoung; Hong, Seong Sook; Cho, Yong Jin; Doo, Seung Whan; Yang, Won Jae; Song, Yun Seob

2016-10-12

The aim of this study was to investigate the diagnostic accuracy of contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance imaging (MRI) of small renal masses in real practice. Contrast-enhanced CT and MRI were performed between February 2008 and February 2013 on 68 patients who had suspected small (≤4 cm) renal cell carcinoma (RCC) based on ultrasonographic measurements. CT and MRI radiographs were reviewed, and the findings of small renal masses were re-categorized into five dichotomized scales by the same two radiologists who had interpreted the original images. Receiver operating characteristics curve analysis was performed, and sensitivity and specificity were determined. Among the 68 patients, 60 (88.2 %) had RCC and eight had benign disease. The diagnostic accuracy rates of contrast-enhanced CT and MRI were 79.41 and 88.23 %, respectively. Diagnostic accuracy was greater when using contrast-enhanced MRI because too many masses (67.6 %) were characterized as "4 (probably solid cancer) or 5 (definitely solid cancer)." The sensitivity of contrast-enhanced CT and MRI for predicting RCC were 79.7 and 88.1 %, respectively. The specificities of contrast-enhanced CT and MRI for predicting RCC were 44.4 and 33.3 %, respectively. Fourteen diagnoses (20.5 %) were missed or inconsistent compared with the final pathological diagnoses. One appropriate nephroureterectomy and five unnecessary percutaneous biopsies were performed for RCC. Seven unnecessary partial nephrectomies were performed for benign disease. Although contrast-enhanced CT and MRI showed high sensitivity for detecting small renal masses, specificity remained low.

The Stockholm-3 (STHLM3) Model can Improve Prostate Cancer Diagnostics in Men Aged 50-69 yr Compared with Current Prostate Cancer Testing.

PubMed

Eklund, Martin; Nordström, Tobias; Aly, Markus; Adolfsson, Jan; Wiklund, Peter; Brandberg, Yvonne; Thompson, James; Wiklund, Fredrik; Lindberg, Johan; Presti, Joseph C; StLezin, Mark; Clements, Mark; Egevad, Lars; Grönberg, Henrik

2016-11-23

Prostate cancer screening is associated with low specificity, unnecessary biopsies, and overdiagnosis. We have previously shown that the Stockholm-3 model (S3M) can reduce biopsies compared with using prostate-specific antigen (PSA) ≥3ng/ml as an indication for biopsy. Urologists in today's current prostate cancer testing (CPT) have access to numerous variables in addition to PSA (eg, age, ethnicity, family history, free PSA, PSA velocity, digital rectal examination, and prostate volume) to support biopsy decisions. We estimated the number of prostate cancers diagnosed and prostate biopsies performed if S3M replaced CPT in Stockholm, Sweden, by comparing biopsy results in 56 282 men who underwent PSA testing according to CPT in Stockholm in 2011 with the 47 688 men enrolled in the STHLM3 validation cohort 2012-2015. With the same sensitivity as CPT to diagnose Gleason score ≥7 prostate cancer, S3M was estimated to reduce the number of men biopsied by 53% (95% confidence interval [CI]: 41-65%), avoid 76% (95% CI: 67-81%) of negative biopsies, and reduce Gleason score 6 cancers by 23% (95% CI: 6-40%). S3M has the potential to improve prostate cancer diagnostics by better selecting men with high risk of GS ≥7 prostate cancer. We modeled the effect the Stockholm-3 model would have on prostate cancer diagnostics if it replaced current clinical practice. We found that Stockholm-3 model may substantially reduce the number of biopsies, while maintaining the same sensitivity to diagnose clinically significant prostate cancer. Copyright © 2016. Published by Elsevier B.V.

Deep Sequencing of Urinary RNAs for Bladder Cancer Molecular Diagnostics.

PubMed

Sin, Mandy L Y; Mach, Kathleen E; Sinha, Rahul; Wu, Fan; Trivedi, Dharati R; Altobelli, Emanuela; Jensen, Kristin C; Sahoo, Debashis; Lu, Ying; Liao, Joseph C

2017-07-15

Purpose: The majority of bladder cancer patients present with localized disease and are managed by transurethral resection. However, the high rate of recurrence necessitates lifetime cystoscopic surveillance. Developing a sensitive and specific urine-based test would significantly improve bladder cancer screening, detection, and surveillance. Experimental Design: RNA-seq was used for biomarker discovery to directly assess the gene expression profile of exfoliated urothelial cells in urine derived from bladder cancer patients ( n = 13) and controls ( n = 10). Eight bladder cancer specific and 3 reference genes identified by RNA-seq were quantitated by qPCR in a training cohort of 102 urine samples. A diagnostic model based on the training cohort was constructed using multiple logistic regression. The model was further validated in an independent cohort of 101 urines. Results: A total of 418 genes were found to be differentially expressed between bladder cancer and controls. Validation of a subset of these genes was used to construct an equation for computing a probability of bladder cancer score (P BC ) based on expression of three markers ( ROBO1, WNT5A , and CDC42BPB ). Setting P BC = 0.45 as the cutoff for a positive test, urine testing using the three-marker panel had overall 88% sensitivity and 92% specificity in the training cohort. The accuracy of the three-marker panel in the independent validation cohort yielded an AUC of 0.87 and overall 83% sensitivity and 89% specificity. Conclusions: Urine-based molecular diagnostics using this three-marker signature could provide a valuable adjunct to cystoscopy and may lead to a reduction of unnecessary procedures for bladder cancer diagnosis. Clin Cancer Res; 23(14); 3700-10. ©2017 AACR . ©2017 American Association for Cancer Research.

[Economic evaluation of rapid diagnostic tests in malaria treatment].

PubMed

Faye, Adama; Ndiaye, Papa; Diagne-Camara, Maty; Badiane, Ousseynou; Wone, Issa; Diongue, Mayassine; Seck, Ibrahima; Dia, Anta Tal; Dia, Amadou Lamine

2010-01-01

This study aimed to evaluate the economic implications of rapid diagnostic tests (RDTs) on malaria management through the rational use of artemisinin-based combination therapy (ACT). The study was carried out in 2006 from November 10th to December 10th; it focused on patients who were seen and treated with ACT for suspicion of uncomplicated malaria in the health district of Ziguinchor, Senegal. The variables studied included age, sex, RDT results, and costs of care and RDT. The cost of care for malaria, estimated in CFA Francs, was evaluated both with and without the use of RDT. Among the 379 patients, 25,1% were aged 0-4 years, 12,7% of 5-14 years and 62,2% of at least 15 years; 51% were women. The result of the RDT was negative in 60% of cases. Without the use of diagnostic testing, the cost of care for all 379 cases was estimated at 299 957 CFA: patient contributions would cover 184 500 CFA and the State would cover the rest (115 457 CFA). With the use of RDTs, the overall cost of the RDT screening for 379 patients and the cost of treatment for the 150 positive cases amounted to 254 786 CFA, with patients bearing the cost of 205 550 CFA and the State subsidizing up to 49 236 CFA. RDT can help identify the positive cases of malaria, and avoid up to 60% of unnecessary treatments, corresponding to an estimated 27 297 cases at the district level and 584 630 cases nationally. The RDT also allow a more rational use of ACTs and a lower risk of emergence of Plasmodium resistance. The use of RDTs could result in savings of 45 171 CFA at the level of the district health centre and 111 240 136 CFA nationally.

Cost-effectiveness of functional cardiac imaging in the diagnostic work-up of coronary heart disease.

PubMed

Pletscher, Mark; Walker, Simon; Moschetti, Karine; Pinget, Christophe; Wasserfallen, Jean-Blaise; Greenwood, John P; Schwitter, Juerg; Girardin, François R

2016-07-01

The aim of this study was to assess the cost-effectiveness of eight common diagnostic work-up strategies for coronary heart disease (CHD) in patients with stable angina symptoms in Switzerland. A decision analytical model was used to perform a cost-effectiveness comparison of eight common multitest strategies to diagnose CHD using combinations of four diagnostic techniques: exercise treadmill test (ETT), single-photon emission computed tomography (SPECT), cardiac magnetic resonance imaging (CMR), and coronary angiography (CA). We used a Markov state transition model to extrapolate the results over a life-time horizon, from a third-party payer perspective. We used a CHD prevalence rate of 39% in patients and a base-case scenario with 60-year-old male patients with intermediate symptom severity Canadian Cardiovascular Society grading of angina pectoris 2 and at least one cardiovascular (CV) risk factor but without a history of myocardial infarction and without need for revascularization. Among the eight work-up strategies, one strategy was dominant, i.e. least costly and most effective: ETT followed by CMR if the ETT result was inconclusive and then CA if the CMR result was positive or inconclusive. The CMR features a favourable balance between false-negative diagnoses, associated with an elevated risk of CV events, and false-positive diagnoses, leading to unnecessary CA and related mortality. Key parameters guiding the diagnostic strategy are the prevalence of CHD in patients with angina symptoms and the diagnostic costs of CA and CMR. Cardiac magnetic resonance imaging appears to be a cost-effective work-up strategy compared with other regimens using SPECT or direct CA. Cardiac magnetic resonance imaging should be more widely recommended as a diagnostic procedure for patients with suspected angina symptoms.

Performance of 4 Point-of-Care Screening Tests for Feline Leukemia Virus and Feline Immunodeficiency Virus.

PubMed

Levy, J K; Crawford, P Cynda; Tucker, S J

2017-03-01

More than 3 million cats in the United States are infected with FeLV or FIV. The cornerstone of control is identification and segregation of infected cats. To compare test performance with well-characterized clinical samples of currently available FeLV antigen/FIV antibody combination test kits. Surplus serum and plasma from diagnostic samples submitted by animal shelters, diagnostic laboratories, veterinary clinics, and cat research colonies. None of the cats had been vaccinated against FIV. The final sample set included 146 FeLV+, 154 FeLV-, 94 FIV+, and 97 FIV- samples. Prospective, blind comparison to a gold standard: Samples were evaluated in 4 different point-of-care tests by ELISA antigen plate tests (FeLV) and virus isolation (FIV) as the reference standards. All test results were visually read by 2 blinded observers. Sensitivity and specificity, respectively, for FeLV were SNAP ® (100%/100%), WITNESS ® (89.0%/95.5%), Anigen ® (91.8%/95.5%), and VetScan ® (85.6%/85.7%). Sensitivity and specificity for FIV were SNAP ® (97.9%/99.0%), WITNESS ® (94.7%/100%), Anigen ® (96.8%/99.0%), and VetScan ® (91.5%/99.0%). The SNAP ® test had the best performance for FeLV, but there were no significant differences for FIV. In typical cat populations with seroprevalence of 1-5%, a majority of positive results reported by most point-of-care test devices would be false-positives. This could result in unnecessary segregation or even euthanasia. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Diagnostic testing for celiac disease among patients with abdominal symptoms: a systematic review.

PubMed

van der Windt, Daniëlle A W M; Jellema, Petra; Mulder, Chris J; Kneepkens, C M Frank; van der Horst, Henriëtte E

2010-05-05

The symptoms and consequences of celiac disease usually resolve with a lifelong gluten-free diet. However, clinical presentation is variable and most patients presenting with abdominal symptoms in primary care will not have celiac disease and unnecessary diagnostic testing should be avoided. To summarize evidence on the performance of diagnostic tests for identifying celiac disease in adults presenting with abdominal symptoms in primary care or similar settings. A literature search via MEDLINE (beginning in January 1966) and EMBASE (beginning in January 1947) through December 2009 and a manual search of references for additional relevant studies. Diagnostic studies were selected if they had a cohort or nested case-control design, enrolled adults presenting with nonacute abdominal symptoms, the prevalence of celiac disease was 15% or less, and the tests used included gastrointestinal symptoms or serum antibody tests. Quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool and data extraction were performed by 2 reviewers independently. Sensitivities and specificities were calculated for each study and pooled estimates were computed using bivariate analysis if there was clinical and statistical homogeneity. Sixteen studies were included in the review (N = 6085 patients). The performance of abdominal symptoms varied widely. The sensitivity of diarrhea, for example, ranged from 0.27 to 0.86 and specificity from 0.21 to 0.86. Pooled estimates for IgA antiendomysial antibodies (8 studies) were 0.90 (95% confidence interval [CI], 0.80-0.95) for sensitivity and 0.99 (95% CI, 0.98-1.00) for specificity (positive likelihood ratio [LR] of 171 and negative LR of 0.11). Pooled estimates for IgA antitissue transglutaminase antibodies (7 studies) were 0.89 (95% CI, 0.82-0.94) and 0.98 (95% CI, 0.95-0.99), respectively (positive LR of 37.7 and negative LR of 0.11). The IgA and IgG antigliadin antibodies showed variable results, especially for sensitivity (range, 0.46-0.87 and range, 0.25-0.93, respectively). One recent study using diamidated gliadin peptides showed good specificity (> or = 0.94), but evidence is limited in this target population. Among adult patients presenting with abdominal symptoms in primary care or other unselected populations, IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies have high sensitivity and specificity for diagnosing celiac disease.

Retrospective analysis supports algorithm as efficient diagnostic approach to treatable intellectual developmental disabilities.

PubMed

Sayson, Bryan; Popurs, Marioara Angela Moisa; Lafek, Mirafe; Berkow, Ruth; Stockler-Ipsiroglu, Sylvia; van Karnebeek, Clara D M

2015-05-01

Intellectual developmental disorders (IDD(1)), characterized by a significant impairment in cognitive function and behavior, affect 2.5% of the population and are associated with considerable morbidity and healthcare costs. Inborn errors of metabolism (IEM) currently constitute the largest group of genetic defects presenting with IDD, which are amenable to causal therapy. Recently, we created an evidence-based 2-tiered diagnostic protocol (TIDE protocol); the first tier is a 'screening step' applied in all patients, comprising routinely performed, wide available metabolic tests in blood and urine, while second-tier tests are more specific and based on the patient's phenotype. The protocol is supported by an app (www.treatable-ID.org). To retrospectively examine the cost- and time-effectiveness of the TIDE protocol in patients identified with a treatable IEM at the British Columbia Children's Hospital. We searched the database for all IDD patients diagnosed with a treatable IEM, during the period 2000-2009 in our academic institution. Data regarding the patient's clinical phenotype, IEM, diagnostic tests and interval were collected. Total costs and time intervals associated with all testing and physician consultations actually performed were calculated and compared to the model of the TIDE protocol. Thirty-one patients (16 males) were diagnosed with treatable IDD during the period 2000-2009. For those identifiable via the 1st tier (n=20), the average cost savings would have been $311.17 CAD, and for those diagnosed via a second-tier test (n=11) $340.14 CAD. Significant diagnostic delay (mean 9 months; range 1-29 months) could have been avoided in 9 patients with first-tier diagnoses, had the TIDE protocol been used. For those with second-tier treatable IDD, diagnoses could have been more rapidly achieved with the use of the Treatable IDD app allowing for specific searches based on signs and symptoms. The TIDE protocol for treatable forms of IDD appears effective reducing diagnostic delay and unnecessary costs. Larger prospective studies, currently underway, are needed to prove that standard screening for treatable conditions in patients with IDD is time- and cost-effective, and most importantly will preserve brain function by timely diagnosis enabling initiation of causal therapy. Copyright © 2015 Elsevier Inc. All rights reserved.

Reducing unnecessary lab testing in the ICU with artificial intelligence.

PubMed

Cismondi, F; Celi, L A; Fialho, A S; Vieira, S M; Reti, S R; Sousa, J M C; Finkelstein, S N

2013-05-01

To reduce unnecessary lab testing by predicting when a proposed future lab test is likely to contribute information gain and thereby influence clinical management in patients with gastrointestinal bleeding. Recent studies have demonstrated that frequent laboratory testing does not necessarily relate to better outcomes. Data preprocessing, feature selection, and classification were performed and an artificial intelligence tool, fuzzy modeling, was used to identify lab tests that do not contribute an information gain. There were 11 input variables in total. Ten of these were derived from bedside monitor trends heart rate, oxygen saturation, respiratory rate, temperature, blood pressure, and urine collections, as well as infusion products and transfusions. The final input variable was a previous value from one of the eight lab tests being predicted: calcium, PTT, hematocrit, fibrinogen, lactate, platelets, INR and hemoglobin. The outcome for each test was a binary framework defining whether a test result contributed information gain or not. Predictive modeling was applied to recognize unnecessary lab tests in a real world ICU database extract comprising 746 patients with gastrointestinal bleeding. Classification accuracy of necessary and unnecessary lab tests of greater than 80% was achieved for all eight lab tests. Sensitivity and specificity were satisfactory for all the outcomes. An average reduction of 50% of the lab tests was obtained. This is an improvement from previously reported similar studies with average performance 37% by [1-3]. Reducing frequent lab testing and the potential clinical and financial implications are an important issue in intensive care. In this work we present an artificial intelligence method to predict the benefit of proposed future laboratory tests. Using ICU data from 746 patients with gastrointestinal bleeding, and eleven measurements, we demonstrate high accuracy in predicting the likely information to be gained from proposed future lab testing for eight common GI related lab tests. Future work will explore applications of this approach to a range of underlying medical conditions and laboratory tests. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Reducing unnecessary lab testing in the ICU with artificial intelligence

PubMed Central

Cismondi, F.; Celi, L.A.; Fialho, A.S.; Vieira, S.M.; Reti, S.R.; Sousa, J.M.C.; Finkelstein, S.N.

2017-01-01

Objectives To reduce unnecessary lab testing by predicting when a proposed future lab test is likely to contribute information gain and thereby influence clinical management in patients with gastrointestinal bleeding. Recent studies have demonstrated that frequent laboratory testing does not necessarily relate to better outcomes. Design Data preprocessing, feature selection, and classification were performed and an artificial intelligence tool, fuzzy modeling, was used to identify lab tests that do not contribute an information gain. There were 11 input variables in total. Ten of these were derived from bedside monitor trends heart rate, oxygen saturation, respiratory rate, temperature, blood pressure, and urine collections, as well as infusion products and transfusions. The final input variable was a previous value from one of the eight lab tests being predicted: calcium, PTT, hematocrit, fibrinogen, lactate, platelets, INR and hemoglobin. The outcome for each test was a binary framework defining whether a test result contributed information gain or not. Patients Predictive modeling was applied to recognize unnecessary lab tests in a real world ICU database extract comprising 746 patients with gastrointestinal bleeding. Main results Classification accuracy of necessary and unnecessary lab tests of greater than 80% was achieved for all eight lab tests. Sensitivity and specificity were satisfactory for all the outcomes. An average reduction of 50% of the lab tests was obtained. This is an improvement from previously reported similar studies with average performance 37% by [1–3]. Conclusions Reducing frequent lab testing and the potential clinical and financial implications are an important issue in intensive care. In this work we present an artificial intelligence method to predict the benefit of proposed future laboratory tests. Using ICU data from 746 patients with gastrointestinal bleeding, and eleven measurements, we demonstrate high accuracy in predicting the likely information to be gained from proposed future lab testing for eight common GI related lab tests. Future work will explore applications of this approach to a range of underlying medical conditions and laboratory tests. PMID:23273628

Prostate cancer diagnostics: Clinical challenges and the ongoing need for disruptive and effective diagnostic tools.

PubMed

Sharma, Shikha; Zapatero-Rodríguez, Julia; O'Kennedy, Richard

The increased incidence and the significant health burden associated with carcinoma of the prostate have led to substantial changes in its diagnosis over the past century. Despite technological advancements, the management of prostate cancer has become progressively more complex and controversial for both early and late-stage disease. The limitations and potential harms associated with the use of prostate-specific antigen (PSA) as a diagnostic marker have stimulated significant investigation of numerous novel biomarkers that demonstrate varying capacities to detect prostate cancer and can decrease unnecessary biopsies. However, only a few of these markers have been approved for specific clinical settings while the others have not been adequately validated for use. This review systematically and critically assesses ongoing issues and emerging challenges in the current state of prostate cancer diagnostic tools and the need for disruptive next generation tools based on analysis of combinations of these biomarkers to enhance predictive accuracy which will benefit clinical diagnostics and patient welfare. Copyright © 2016. Published by Elsevier Inc.

Can routine automated urinalysis reduce culture requests?

PubMed

Kayalp, Damla; Dogan, Kubra; Ceylan, Gozde; Senes, Mehmet; Yucel, Dogan

2013-09-01

There are a substantial number of unnecessary urine culture requests. We aimed to investigate whether urine dipstick and microscopy results could accurately rule out urinary tract infection (UTI) without urine culture. The study included a total of 32,998 patients (11,928 men and 21,070 women, mean age: 39 ± 32 years) with a preliminary diagnosis of UTI and both urinalysis and urinary culture were requested. All urine cultures were retrospectively reviewed; association of culture positivity with a positive urinalysis result for leukocyte esterase (LE) and nitrite in chemical analysis and pyuria (WBC) and bacteriuria in microscopy was determined. Diagnostic performance of urinalysis parameters for detection of UTI was evaluated. In total, 758 (2.3%) patients were positive by urine culture. Out of these culture positive samples, ratios of positive dipstick results for LE and nitrite were 71.0% (n=538) and 17.7% (n=134), respectively. The positive microscopy results for WBC and bacteria were 68.2% (n=517) and 78.8% (n=597), respectively. Negative predictive values for LE, nitrite, bacteriuria and WBC were very close to 100%. Most of the samples have no or insignificant bacterial growth. Urine dipstick and microscopy can accurately rule out UTI. Automated urinalysis is a practicable and faster screening test which may prevent unnecessary culture requests for majority of patients. © 2013. Published by Elsevier Inc. All rights reserved.

Management of pediatric central nervous system emergencies: a review for general radiologists.

PubMed

Rebollo Polo, M

2016-05-01

To review the most common and most important diseases and disorders of the central nervous system (CNS) in pediatric emergencies, discussing the indications for different imaging tests in each context. In pediatric patients, acute neurologic symptoms (seizures, deteriorating level of consciousness, focal neurologic deficits, etc.) can appear in diverse clinical situations (trauma, child abuse, meningoencephalitis, ischemia…). It is important to decide on the most appropriate neuroimaging diagnostic algorithm for each situation and age group, as well as to know the signs of the most typical lesions that help us in the etiological differential diagnosis. Pediatric patients' increased vulnerability to ionizing radiation and the possible need for sedation in studies that require more time are factors that should be taken into account when indicating an imaging test. It is essential to weigh the risks and benefits for the patient and to avoid unnecessary studies. Copyright © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Rapid diagnostic tests apply for pediatric infections at outpatient clinic setting.

PubMed

Ushijima, Hiroshi; Thongprachum, Aksara; Tran, Dinh Nguyen; Fujimoto, Tsuguto; Hanaoka, Nozomu; Okitsu, Shoko; Takanashi, Sayaka; Mizuguchi, Masashi; Hayakawa, Satoshi

2015-01-01

Early identification of the etiology of infection is beneficial. Most infections are treated as outpatients. However, facilities for rapid diagnosis are not available in clinic settings. We applied Immunochromatography (IC) and Loop-mediated Isothermal Amplification (LAMP) methods to rapidly diagnose pathogens among 31 children with respiratory infection and 12 with gastroenteritis at a clinic in Saitama prefecture, Japan. Pathogens were then screened by multiplex conventional and real-time PCRs and bacterial culture. Respiratory pathogens were found in 64.5%. Despite the narrow spectrum, rapid tests identified pathogens in 28.6% of cases with a high agreement rate of 89.3% with PCR. Gastroenteritis pathogens were found in 66.7%. E. coli was positive in 3 cases and all were negative for verotoxin by LAMP. The agreement rate of IC and PCR assay was high, 100%. IC and LAMP are reliable and suitable methods in limited-resource settings for early pathogenic identification, which will help appropriate management, avoid unnecessary intervention, and cost saving.

Pathways in heart failure disease management across socioeconomic spectra.

PubMed

Hebert, Kathy; Gogichaishvili, Ilia; Gopie, Stephanie; Arcement, Lee

2011-12-01

Caring for heart failure patients with a low socioeconomic status presents a unique set of challenges for health care providers. Heart failure disease management programs can integrate the use of teaching DVDs to overcome deficiencies in health literacy and take advantage of the Wal-Mart/Target $4 dollar medication program to provide life-saving medical therapy. In addition, open discussions with the patient and family regarding the costs of medications and the reality of what they can afford to pay monthly on a long term basis can guide the physician to prescribing medications by prioritizing use with a focus on evidence-based data for the medications with the highest mortality reduction. Finally, connecting inpatient visits to outpatient visits through the use of electronic medical records systems can facilitate avoidance of unnecessary repeat lab and diagnostic testing.

A case of neuromyotonia and axonal motor neuropathy: A report of a HINT1 mutation in the United States.

PubMed

Jerath, Nivedita U; Shy, Michael E; Grider, Tiffany; Gutmann, Ludwig

2015-12-01

HINT1 mutations cause an autosomal recessive distal hereditary motor axonal neuropathy with neuromyotonia. This is a case report of a HINT1 mutation in the United States. A 30-year-old man of Slovenian heritage and no significant family history presented with scoliosis as a child and later developed neuromyotonia and distal weakness. Electrodiagnostic testing revealed an axonal motor neuropathy and neuromyotonic discharges. Previous diagnostic work-up, including testing for Cx32, MPZ, PMP-22, NF-L, EGR2, CLCN1, DM1, DM2, SMN exon 7/8, emerin, LMNA, MPK, SCNA4, acid maltase gene, paraneoplastic disorder, and a sural nerve biopsy, was negative. Genetic testing for a HINT1 mutation was performed and revealed a homozygous mutation at p.Arg37Pro. This entity should be distinguished clinically and genetically from myotonic dystrophy and channelopathies with the clinical features of neuromyotonia and an axonal neuropathy. This case illustrates the importance of identifying the correct phenotype to avoid unnecessary and costly evaluations. © 2015 Wiley Periodicals, Inc.

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital.

PubMed

Konger, Raymond L; Ndekwe, Paul; Jones, Genea; Schmidt, Ronald P; Trey, Marty; Baty, Eric J; Wilhite, Denise; Munshi, Imtiaz A; Sutter, Bradley M; Rao, Maddamsetti; Bashir, Chowdry M

2016-03-01

To implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing. The LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team. Since implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at $151,184 and $163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged. Electronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care. Published by Oxford University Press on behalf of the American Society for Clinical Pathology, 2016. This work is written by US Government employees and is in the public domain in the US.

A Web-based Decision Tool to Estimate Subarachnoid Hemorrhage Risk in Emergency Department Patients

PubMed Central

Manella, Haley; Sivasankar, Shyam; Perry, Jeffrey J; Pfeil, Sam; Senyak, Josh; Shachter, Ross

2018-01-01

Subarachnoid hemorrhage (SAH) from a leaking aneurysm is a neurological emergency. SAH patients often present with headache—a common chief complaint among emergency department patients. If unrecognized, 70% of the patients with re-bleeds die and one third are left with neurological deficits. Therefore, it is critical to distinguish the signs and symptoms of SAH from benign causes of headache, perform the appropriate diagnostic tests and treat in a timely manner in order to reduce the disability and mortality associated with this condition. In patients with suspected SAH, traditional diagnostic strategies in the emergency department employ non-contrast computed tomography (CT) of the brain to detect blood in the subarachnoid space followed by lumbar puncture if there is a high clinical probability of aneurysmal bleed without any evidence of blood on CT scan. While the older generation CT scanners were less sensitive to blood detection in the subarachnoid space, recent advances in CT imaging have resulted in sensitivity approaching 100% for detection of blood in the subarachnoid space specifically within six hours of symptom onset. Therefore, the benefit of lumbar puncture is controversial when performed within the first six hours of symptom onset. Despite this, lumbar puncture is still commonly performed in the emergency department, exposing patients to unnecessary procedural risks. The objective of this research study is to develop a web-based risk calculator that estimates the risk of SAH based on time to emergency department presentation after symptom onset, physical findings and imaging characteristics with the goal of reducing unnecessary lumbar punctures in the emergency department. In this technical report, we describe the prototype calculator, the mathematical basis of the model and provide a link to the web-based prototype. In the future, we will refine the prototype, make it user-friendly to physicians, staff and patients and study its benefits in the emergency department. PMID:29568717

Effect of a Stewardship Intervention on Adherence to Uncomplicated Cystitis and Pyelonephritis Guidelines in an Emergency Department Setting

PubMed Central

Hecker, Michelle T.; Fox, Clinton J.; Son, Andrea H.; Cydulka, Rita K.; Siff, Jonathan E.; Emerman, Charles L.; Sethi, Ajay K.; Muganda, Christine P.; Donskey, Curtis J.

2014-01-01

Objective To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention. Methods The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2). Results Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods. Conclusions A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI. PMID:24498394

Provider management strategies of abnormal test result alerts: a cognitive task analysis

PubMed Central

Sawhney, Mona K; Wilson, Lindsay; Sittig, Dean F; Espadas, Donna; Davis, Traber; Singh, Hardeep

2010-01-01

Objective Electronic medical records (EMRs) facilitate abnormal test result communication through “alert” notifications. The aim was to evaluate how primary care providers (PCPs) manage alerts related to critical diagnostic test results on their EMR screens, and compare alert-management strategies of providers with high versus low rates of timely follow-up of results. Design 28 PCPs from a large, tertiary care Veterans Affairs Medical Center (VAMC) were purposively sampled according to their rates of timely follow-up of alerts, determined in a previous study. Using techniques from cognitive task analysis, participants were interviewed about how and when they manage alerts, focusing on four alert-management features to filter, sort and reduce unnecessary alerts on their EMR screens. Results Provider knowledge of alert-management features ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two. Providers with higher versus lower rates of timely follow-up used the four features similarly, except one (customizing alert notifications). Providers with low rates of timely follow-up tended to manually scan the alert list and process alerts heuristically using their clinical judgment. Additionally, 46% of providers used at least one workaround strategy to manage alerts. Conclusion Considerable heterogeneity exists in provider use of alert-management strategies; specific strategies may be associated with lower rates of timely follow-up. Standardization of alert-management strategies including improving provider knowledge of appropriate tools in the EMR to manage alerts could reduce the lack of timely follow-up of abnormal diagnostic test results. PMID:20064805

Provider management strategies of abnormal test result alerts: a cognitive task analysis.

PubMed

Hysong, Sylvia J; Sawhney, Mona K; Wilson, Lindsay; Sittig, Dean F; Espadas, Donna; Davis, Traber; Singh, Hardeep

2010-01-01

Electronic medical records (EMRs) facilitate abnormal test result communication through "alert" notifications. The aim was to evaluate how primary care providers (PCPs) manage alerts related to critical diagnostic test results on their EMR screens, and compare alert-management strategies of providers with high versus low rates of timely follow-up of results. 28 PCPs from a large, tertiary care Veterans Affairs Medical Center (VAMC) were purposively sampled according to their rates of timely follow-up of alerts, determined in a previous study. Using techniques from cognitive task analysis, participants were interviewed about how and when they manage alerts, focusing on four alert-management features to filter, sort and reduce unnecessary alerts on their EMR screens. Provider knowledge of alert-management features ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two. Providers with higher versus lower rates of timely follow-up used the four features similarly, except one (customizing alert notifications). Providers with low rates of timely follow-up tended to manually scan the alert list and process alerts heuristically using their clinical judgment. Additionally, 46% of providers used at least one workaround strategy to manage alerts. Considerable heterogeneity exists in provider use of alert-management strategies; specific strategies may be associated with lower rates of timely follow-up. Standardization of alert-management strategies including improving provider knowledge of appropriate tools in the EMR to manage alerts could reduce the lack of timely follow-up of abnormal diagnostic test results.

What are people willing to pay for whole-genome sequencing information, and who decides what they receive?

PubMed

Marshall, Deborah A; Gonzalez, Juan Marcos; Johnson, F Reed; MacDonald, Karen V; Pugh, Amy; Douglas, Michael P; Phillips, Kathryn A

2016-12-01

Whole-genome sequencing (WGS) can be used as a powerful diagnostic tool as well as for screening, but it may lead to anxiety, unnecessary testing, and overtreatment. Current guidelines suggest reporting clinically actionable secondary findings when diagnostic testing is performed. We examined preferences for receiving WGS results. A US nationally representative survey (n = 410 adults) was used to rank preferences for who decides (an expert panel, your doctor, you) which WGS results are reported. We estimated the value of information about variants with varying levels of clinical usefulness by using willingness to pay contingent valuation questions. The results were as follows: 43% preferred to decide themselves what information is included in the WGS report. 38% (95% confidence interval (CI): 33-43%) would not pay for actionable variants, and 3% (95% CI: 1-5%) would pay more than $1,000. 55% (95% CI: 50-60%) would not pay for variants for which medical treatment is currently unclear, and 7% (95% CI: 5-9%) would pay more than $400. Most people prefer to decide what WGS results are reported. Despite valuing actionable information more, some respondents perceive that genetic information could negatively impact them. Preference heterogeneity for WGS information should be considered in the development of policies, particularly to integrate patient preferences with personalized medicine and shared decision making.Genet Med 18 12, 1295-1302.

Health workers' compliance to rapid diagnostic tests (RDTs) to guide malaria treatment: a systematic review and meta-analysis.

PubMed

Kabaghe, Alinune N; Visser, Benjamin J; Spijker, Rene; Phiri, Kamija S; Grobusch, Martin P; van Vugt, Michèle

2016-03-15

The World Health Organization recommends malaria to be confirmed by either microscopy or a rapid diagnostic test (RDT) before treatment. The correct use of RDTs in resource-limited settings facilitates basing treatment onto a confirmed diagnosis; contributes to speeding up considering a correct alternative diagnosis, and prevents overprescription of anti-malarial drugs, reduces costs and avoids unnecessary exposure to adverse drug effects. This review aims to evaluate health workers' compliance to RDT results and factors contributing to compliance. A PROSPERO-registered systematic review was conducted to evaluate health workers' compliance to RDTs in sub-Saharan Africa, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published up to November 2015 were searched without language restrictions in Medline/Ovid, Embase, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, Biosis Previews and the African Index Medicus. The primary outcome was health workers treating patients according to the RDT results obtained. The literature search identified 474 reports; 14 studies were eligible and included in the quantitative analysis. From the meta-analysis, health workers' overall compliance in terms of initiating treatment or not in accordance with the respective RDT results was 83% (95% CI 80-86%). Compliance to positive and negative results was 97% (95% CI 94-99%) and 78% (95% CI 66-89%), respectively. Community health workers had higher compliance rates to negative test results than clinicians. Patient expectations, work experience, scepticism of results, health workers' cadres and perceived effectiveness of the test, influenced compliance. With regard to published data, compliance to RDT appears to be generally fair in sub-Saharan Africa; compliance to negative results will need to improve to prevent mismanagement of patients and overprescribing of anti-malarial drugs. Improving diagnostic capacity for other febrile illnesses and developing local evidence-based guidelines may help improve compliance and management of negative RDT results. CRD42015016151 (PROSPERO).

New scoring system for intra-abdominal injury diagnosis after blunt trauma.

PubMed

Shojaee, Majid; Faridaalaee, Gholamreza; Yousefifard, Mahmoud; Yaseri, Mehdi; Arhami Dolatabadi, Ali; Sabzghabaei, Anita; Malekirastekenari, Ali

2014-01-01

An accurate scoring system for intra-abdominal injury (IAI) based on clinical manifestation and examination may decrease unnecessary CT scans, save time, and reduce healthcare cost. This study is designed to provide a new scoring system for a better diagnosis of IAI after blunt trauma. This prospective observational study was performed from April 2011 to October 2012 on patients aged above 18 years and suspected with blunt abdominal trauma (BAT) admitted to the emergency department (ED) of Imam Hussein Hospital and Shohadaye Hafte Tir Hospital. All patients were assessed and treated based on Advanced Trauma Life Support and ED protocol. Diagnosis was done according to CT scan findings, which was considered as the gold standard. Data were gathered based on patient's history, physical exam, ultrasound and CT scan findings by a general practitioner who was not blind to this study. Chi-square test and logistic regression were done. Factors with significant relationship with CT scan were imported in multivariate regression models, where a coefficient (β) was given based on the contribution of each of them. Scoring system was developed based on the obtained total β of each factor. Altogether 261 patients (80.1% male) were enrolled (48 cases of IAI). A 24-point blunt abdominal trauma scoring system (BATSS) was developed. Patients were divided into three groups including low (score<8), moderate (8≤score<12) and high risk (score≥12). In high risk group immediate laparotomy should be done, moderate group needs further assessments, and low risk group should be kept under observation. Low risk patients did not show positive CT-scans (specificity 100%). Conversely, all high risk patients had positive CT-scan findings (sensitivity 100%). The receiver operating characteristic curve indicated a close relationship between the results of CT scan and BATSS (sensitivity=99.3%). The present scoring system furnishes a high precision and reproducible diagnostic tool for BAT detection and has the potential to reduce unnecessary CT scan and cut unnecessary costs.

Polyuria and polydipsia in a young child: diagnostic considerations and identification of novel mutation causing familial neurohypophyseal diabetes insipidus.

PubMed

Stephen, Matthew D; Fenwick, Raymond G; Brosnan, Patrick G

2012-12-01

A 3-year 5-month-old boy was seen for second opinion regarding polydipsia and polyuria. Previously, a diagnosis of primary polydipsia was made after normal urine concentration after overnight water deprivation testing. The boy's father, paternal grandfather, and paternal aunt had diabetes insipidus treated with desmopressin acetate. Based on this young boy's symptoms, ability to concentrate urine after informal overnight water deprivation, and family history of diabetes insipidus, we performed AVP gene mutation testing. Analysis of the AVP gene revealed a novel mutation G54E that changes a normal glycine to glutamic acid, caused by a guanine to adenine change at nucleotide g.1537 (exon 2) of the AVP gene. Commonly, patients with familial neurohypophyseal diabetes insipidus (FNHDI) present within the first 6 years of life with progressively worsening polyuria and compensatory polydipsia. Since these patients have progressive loss of arginine vasopressin (AVP), they may initially respond normally to water deprivation testing and have normal pituitary findings on brain MRI. Genetic testing may be helpful in these patients, as well as preemptively diagnosing those with a mutation, thereby avoiding unnecessary surveillance of those unaffected.

Blood collection tubes as medical devices: The potential to affect assays and proposed verification and validation processes for the clinical laboratory.

PubMed

Bowen, Raffick A R; Adcock, Dorothy M

2016-12-01

Blood collection tubes (BCTs) are an often under-recognized variable in the preanalytical phase of clinical laboratory testing. Unfortunately, even the best-designed and manufactured BCTs may not work well in all clinical settings. Clinical laboratories, in collaboration with healthcare providers, should carefully evaluate BCTs prior to putting them into clinical use to determine their limitations and ensure that patients are not placed at risk because of inaccuracies due to poor tube performance. Selection of the best BCTs can be achieved through comparing advertising materials, reviewing the literature, observing the device at a scientific meeting, receiving a demonstration, evaluating the device under simulated conditions, or testing the device with patient samples. Although many publications have discussed method validations, few detail how to perform experiments for tube verification and validation. This article highlights the most common and impactful variables related to BCTs and discusses the validation studies that a typical clinical laboratory should perform when selecting BCTs. We also present a brief review of how in vitro diagnostic devices, particularly BCTs, are regulated in the United States, the European Union, and Canada. The verification and validation of BCTs will help to avoid the economic and human costs associated with incorrect test results, including poor patient care, unnecessary testing, and delays in test results. We urge laboratorians, tube manufacturers, diagnostic companies, and other researchers to take all the necessary steps to protect against the adverse effects of BCT components and their additives on clinical assays. Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

A novel approach to cardiac troponins to improve the diagnostic work-up in chest pain patients.

PubMed

Eggers, Kai M; Jaffe, Allan S; Svennblad, Bodil; Lindahl, Bertil

2012-12-01

In patients with acute chest pain, current guidelines recommend serial measurements of cardiac troponins at predefined and partly late time points. Consequently, diagnostic assessment in these patients tends to be lengthy and often results in unnecessary admissions. We, therefore, evaluated whether an approach integrating troponin results into the clinical context provided by the individual patient's presentation might facilitate the early diagnostic work-up. In 197 chest pain patients, cardiac troponin I (cTnI; Stratus CS) was measured serially within 12 hours after hospital admission. In patient cohorts with different chances of having myocardial infarction (MI) according to clinical data, electrocardiographic findings, and admission biomarker results, pretest probabilities for MI were calculated and compared with posttest probabilities derived from subsequent cTnI results after admission. Elevated cTnI levels at 1 to 2 hours after admission revealed ≥95.0% posttest probabilities for MI in cohorts with intermediate or high chances of having MI. The posttest probabilities for the absence of MI were 94.7% to 98.2% in cohorts with low or intermediate chances of having MI when cTnI was negative at 2 hours. Troponin testing considering the individual patient's pretest probability of MI seems, in conclusion, to provide clinically useful information already 1 to 2 hours after admission. Such an approach has the potential to identify both patient cohorts in whom early discharge or admittance for further evaluation would be appropriate. This could facilitate the early diagnostic work-up of chest pain patients, thereby improving patient flow and reducing overcrowding in healthcare facilities.

Combining principles of Cognitive Load Theory and diagnostic error analysis for designing job aids: Effects on motivation and diagnostic performance in a process control task.

PubMed

Kluge, Annette; Grauel, Britta; Burkolter, Dina

2013-03-01

Two studies are presented in which the design of a procedural aid and the impact of an additional decision aid for process control were assessed. In Study 1, a procedural aid was developed that avoids imposing unnecessary extraneous cognitive load on novices when controlling a complex technical system. This newly designed procedural aid positively affected germane load, attention, satisfaction, motivation, knowledge acquisition and diagnostic speed for novel faults. In Study 2, the effect of a decision aid for use before the procedural aid was investigated, which was developed based on an analysis of diagnostic errors committed in Study 1. Results showed that novices were able to diagnose both novel faults and practised faults, and were even faster at diagnosing novel faults. This research contributes to the question of how to optimally support novices in dealing with technical faults in process control. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.

LevRad software as a tool to learn how to proceed with an evaluation of barriers.

PubMed

Ferreira, C C; Souza, S O

2011-05-30

We developed the software LevRad with the objective of teaching how to proceed in an analysis of barriers shielding against x-rays to minimize the contact of the professional or the student with x-rays and also to prevent wearing out of the x-ray equipment. Some tests of the software were made, and preliminary results indicate that LevRad is efficient as a complementary tool for the development of professionals related to diagnostic radiology. In the case of education, an advantage is gained when the beginner uses the software before his or her first contact with x-ray equipment in locu. The software introduces a basic knowledge about evaluation of barriers, prevents wearing out of the x—ray tube, reinforces teaching of evaluation of barriers, and reduces the collective effective dose by avoiding unnecessary exposures when possible.

Enthesopathy of the Extensor Carpi Radialis Brevis Origin: Effective Communication Strategies.

PubMed

Drake, Matthew L; Ring, David C

2016-06-01

Enthesopathy of the extensor carpi radialis brevis origin, generally known as tennis elbow, is a common condition arising in middle-aged persons. The diagnosis is typically clear based on the patient interview and physical examination alone; therefore, imaging and other diagnostic tests are usually unnecessary. The natural history of the disorder is spontaneous resolution, but it can last for >1 year. The patient's attitude and circumstances, including stress, distress, and ineffective coping strategies, determine the intensity of the pain and the magnitude of the disability. Despite the best efforts of medical science, no treatments, invasive or noninvasive, have been proven to alter the natural history of the condition. Given the lack of disease-modifying treatments for enthesopathy of the extensor carpi radialis brevis origin, orthopaedic surgeons can benefit from learning effective communication strategies to help convey accurate information that is hopeful and enabling.

Computerized bioterrorism education and training for nurses on bioterrorism attack agents.

PubMed

Nyamathi, Adeline M; Casillas, Adrian; King, Major L; Gresham, Louise; Pierce, Elaine; Farb, Daniel; Wiechmann, Carrie; Weichmann, Carrie

2010-08-01

Biological agents have the ability to cause large-scale mass casualties. For this reason, their likely use in future terrorist attacks is a concern for national security. Recent studies show that nurses are ill prepared to deal with agents used in biological warfare. Achieving a goal for bioterrorism preparedness is directly linked to comprehensive education and training that enables first-line responders such as nurses to diagnose infectious agents rapidly. The study evaluated participants' responses to biological agents using a computerized bioterrorism education and training program versus a standard bioterrorism education and training program. Both programs improved participants' ability to complete and solve case studies involving the identification of specific biological agents. Participants in the computerized bioterrorism education and training program were more likely to solve the cases critically without reliance on expert consultants. However, participants in the standard bioterrorism education and training program reduced the use of unnecessary diagnostic tests.

Clinical Predictors of Shigella and Campylobacter Infection in Children in the United States

PubMed Central

Smith, Timothy; Ye, Xiangyang; Stockmann, Chris; Cohen, Daniel; Leber, Amy; Daly, Judy; Jackson, Jami; Selvarangan, Rangaraj; Kanwar, Neena; Bender, Jeffery; Bard, Jennifer Dien; Festekjian, Ara; Duffy, Susan; Larsen, Chari; Baca, Tanya; Holmberg, Kristen; Bourzac, Kevin; Chapin, Kimberle C; Pavia, Andrew; Leung, Daniel

2017-01-01

Abstract Background Infectious gastroenteritis is a major cause of morbidity and mortality among children worldwide. While most episodes are self-limiting, for select pathogens such as Shigella and Campylobacter, etiological diagnosis may allow effective antimicrobial therapy and aid public health interventions. Unfortunately, clinical predictors of such pathogens are not well established and are based on small studies using bacterial culture for identification. Methods We used prospectively collected data from a multi-center study of pediatric gastroenteritis employing multi-pathogen molecular diagnostics to determine clinical predictors associated with 1) Shigella and 2) Shigella or Campylobacter infection. We used machine learning algorithms for clinical predictor identification, then performed logistic regression on features extracted plus pre-selected variables of interest. Results Of 993 children enrolled with acute diarrhea, we detected Shigella spp. in 56 (5.6%) and Campylobacter spp. in 24 (2.4%). Compared with children who had neither pathogen detected (of whom, >70% had ≥1 potential pathogen identified), bloody diarrhea (odds ratio 4.0), headache (OR 2.2), fever (OR 7.1), summer (OR 3.3), and sick contact with GI illness (OR 2.2), were positively associated with Shigella, and out-of-state travel (OR 0.3) and vomiting and/or nausea (OR 0.4) were negatively associated (Table). For Shigella or Campylobacter, predictors were similar but season was no longer significantly associated with infection. Conclusion These results can create prediction models and assist clinicians with identifying patients who would benefit from diagnostic testing and earlier antibiotic treatment. This may curtail unnecessary antibiotic use, and help to direct and target appropriate use of stool diagnostics. Disclosures A. Leber, BioFIre Diagnostics: Research Contractor and Scientific Advisor, Research support, Speaker honorarium and Travel expenses J. Daly, Biofire: Grant Investigator, Grant recipient R. Selvarangan, BioFire Diagnostics: Board Member and Investigator, Consulting fee and Research grant Luminex Diagnostics: Investigator, Research grant J. Dien Bard, BioFire: Consultant and Investigator, Research grant and Speaker honorarium K. Holmberg, BioFire Diagnostics: Employee, Salary K. Bourzac, BioFire Diagnostics: Employee, Salary K. C. Chapin, BioFire Diagnstics: Investigator, Research support A. Pavia, BioFire Diagnostics: Grant Investigator, Research grant

Value of routine investigations to predict loop diuretic down-titration success in stable heart failure.

PubMed

Martens, Pieter; Verbrugge, Frederik H; Boonen, Levinia; Nijst, Petra; Dupont, Matthias; Mullens, Wilfried

2018-01-01

Guidelines advocate down-titration of loop diuretics in chronic heart failure (CHF) when patients have no signs of volume overload. Limited data are available on the expected success rate of this practice or how routine diagnostic tests might help steering this process. Fifty ambulatory CHF-patients on stable neurohumoral blocker/diuretic therapy for at least 3months without any clinical sign of volume overload were prospectively included to undergo loop diuretic down-titration. All patients underwent a similar pre-down-titration evaluation consisting of a dyspnea scoring, physical examination, transthoracic echocardiography (diastolic function, right ventricular function, cardiac filling pressures and valvular disease), blood sample (serum creatinine, plasma NT-pro-BNP and neurohormones). Loop diuretic maintenance dose was subsequently reduced by 50% or stopped if dose was ≤40mg furosemide equivalents. Successful down-titration was defined as a persistent dose reduction after 30days without weight increase >1.5kg or new-onset symptoms of worsening heart failure. At 30-day follow-up, down-titration was successful in 62% (n=31). In 12/19 patients exhibiting down-titration failure, this occurred within the first week. Physical examination, transthoracic echocardiography and laboratory analysis had limited predictive capability to detect patients with down-titration success/failure (positive likelihood-ratios below 1.5, or area under the curve [AUC] non-statically different from AUC=0.5). Loop diuretic down-titration is feasible in a majority of stable CHF patients in which the treating clinician felt continuation of loops was unnecessary to sustain euvolemia. Importantly, routine diagnostics which suggest euvolemia, have limited diagnostic impact on the post-test probability. Copyright © 2017 Elsevier B.V. All rights reserved.

Computer-assisted assessment of ultrasound real-time elastography: initial experience in 145 breast lesions.

PubMed

Zhang, Xue; Xiao, Yang; Zeng, Jie; Qiu, Weibao; Qian, Ming; Wang, Congzhi; Zheng, Rongqin; Zheng, Hairong

2014-01-01

To develop and evaluate a computer-assisted method of quantifying five-point elasticity scoring system based on ultrasound real-time elastography (RTE), for classifying benign and malignant breast lesions, with pathologic results as the reference standard. Conventional ultrasonography (US) and RTE images of 145 breast lesions (67 malignant, 78 benign) were performed in this study. Each lesion was automatically contoured on the B-mode image by the level set method and mapped on the RTE image. The relative elasticity value of each pixel was reconstructed and classified into hard or soft by the fuzzy c-means clustering method. According to the hardness degree inside lesion and its surrounding tissue, the elasticity score of the RTE image was computed in an automatic way. Visual assessments of the radiologists were used for comparing the diagnostic performance. Histopathologic examination was used as the reference standard. The Student's t test and receiver operating characteristic (ROC) curve analysis were performed for statistical analysis. Considering score 4 or higher as test positive for malignancy, the diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 93.8% (136/145), 92.5% (62/67), 94.9% (74/78), 93.9% (62/66), and 93.7% (74/79) for the computer-assisted scheme, and 89.7% (130/145), 85.1% (57/67), 93.6% (73/78), 92.0% (57/62), and 88.0% (73/83) for manual assessment. Area under ROC curve (Az value) for the proposed method was higher than the Az value for visual assessment (0.96 vs. 0.93). Computer-assisted quantification of classical five-point scoring system can significantly eliminate the interobserver variability and thereby improve the diagnostic confidence of classifying the breast lesions to avoid unnecessary biopsy. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population.

PubMed

Rodríguez Villa, S; Alonso Álvarez, C; de Dios Del Valle, R; Salazar Méndez, R; Cuesta García, M; Ruiz García, M J; Cubillas Martín, M; Rodríguez Vazquez, M

2016-09-01

To identify the prevalence and risk factors of diabetic retinopathy (DR) among rural inhabitants included in a tele-ophthalmology program. To analyse diagnostic accuracy among primary care physicians, concordance with ophthalmologists, and financial savings. An observational randomised study was conducted on 394 patients included in a tele-ophthalmology program (from January 2010 to January 2015). An analysis was performed on the clinical characteristics, DR findings in retinography images, and correspondence between the request for a second interpretation by an ophthalmologist, and previously established criteria for it: presence of moderate to severe DR, vision loss, poor image quality and/or intraocular pressure >22mmHg. Statistical analysis was performed using the SPSS program (Student t and χ(2) tests). DR prevalence was 12.1%. Patients with glycosylated haemoglobin values >7.68% or those treated with a combination of insulin and oral antidiabetic drugs showed a higher risk of DR (P<.05). 43.3% of patients correctly referred to ophthalmologists showed moderate to severe DR. Unnecessary referrals to specialists were improved from 91.7% in 2010 to 98.6% in 2014. It is estimated that the program has made a total saving of €152,550.45. Tele-ophthalmology programs are a useful tool in DR screening. Primary care physicians are able to distinguish patients who need specialist care, avoiding unnecessary referrals to ophthalmologists, and saving costs. Copyright © 2016 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.

Choosing Wisely: The Top-5 Recommendations from the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children.

PubMed

Chiappini, Elena; Bortone, Barbara; Di Mauro, Giuseppe; Esposito, Susanna; Galli, Luisa; Landi, Massimo; Novelli, Andrea; Marchisio, Paola; Marseglia, Gian Luigi; Principi, Nicola; de Martino, Maurizio

2017-03-01

With the aim to reduce waste in the health care system and avoid risks associated with unnecessary treatment, the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children joined the Choosing Wisely initiative. An ad hoc Choosing Wisely task force was selected to develop a candidate list of items for the top-5 list on pharyngitis medicine. Through a process of literature review and consensus, the final list of 5 items was chosen. Drafted recommendations were formulated and then reviewed by the task force members until a final consensus was reached. The 5 recommendations approved are: blood exams should not be performed; antibiotics should not be administrated unless microbiologic confirmation of streptococcal infection has been carried out; if a throat culture is performed, susceptibility tests on isolates should not be executed; antibiotic course should not be shortened; because penicillin V is not available in Italy, amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice treatment; and steroids should not be administered for the risk of masking possible underlying severe condition. This top-5 list can be a novel tool to spread the key messages of guidelines and to avoid unnecessary diagnostic procedures, and to promote a rational use of antibiotics in children. Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.

[From prospective molecular diagnosis of enterovirus meningitis...to the prevention of antibiotic resistance].

PubMed

Peigue-Lafeuille, H; Archimbaud, C; Mirand, A; Chambon, M; Regagnon, C; Laurichesse, H; Clavelou, P; Labbé, A; Bailly, J-L; Henquell, C

2006-03-01

Meningitis initially presents with intense manifestations that are not generally specific to a given etiology. The first major question for the physician is to decide whether to initiate a probabilistic treatment. Enteroviruses are a major cause of aseptic meningitis, which is benign in immunocompetent patients. Molecular diagnosis is now becoming the gold standard and its prospective use at the time of patient admission, on the sole basis of clinical suspicion of meningitis, has yielded more reliable data. Cytological and biochemical data from CSF analyses are of low predictive value to influence the initial decision to treat with antibiotics. In addition, cases of meningitis during winter are not uncommon. Adults are concerned in about 25% of cases. Thus, if molecular diagnostic tools are not rapidly available, patient management may be inconsistent, leading to unnecessary scans, laboratory investigations and treatment (including overconsumption of antibiotics). Current progress in the automation and practicability of viral genomic detection yields the result within a few hours after admission. Rapid molecular viral diagnosis of a benign disease that does not require treatment but which is initially worrying is of unquestionable advantage. It is of benefit to both the patient and the community because of its input on health economics, the needless consumption of drugs and, as a result, resistance to antibiotics. The diagnosis of meningitis can no longer remain a retrospective diagnosis after elimination of all the possible causes, since not prescribing unnecessary laboratory tests and not treating are true therapeutic decisions.

[Overdiagnosis and defensive medicine in occupational medicine].

PubMed

Berral, Alessandro; Pira, Enrico; Romano, Canzio

2014-01-01

In clinical medicine since some years overdiagnosis is giving rise to growing attention and concern. Overdiagnosis is the diagnosis of a "disease" that will never cause symptoms or death during a patient's lifetime. It is a side effect of testing for early forms of disease which may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Four drivers engender overdiagnosis: 1) screening in non symptomatic subjects; 2) raised sensitivity of diagnostic tests; 3) incidental overdiagnosis; 4) broadening of diagnostic criteria for diseases. "Defensive medicine" can play a role. It begs the question of whether even in the context of Occupational Medicine overdiagnosis is possible. In relation to the double diagnostic evaluation peculiar to Occupational Medicine, the clinical and the causal, a dual phenomenon is possible: that of overdiagnosis properly said and what we could define the overattribution, in relation to the assessment of a causal relationship with work. Examples of occupational "diseases" that can represent cases of overdiagnosis, with the possible consequences of overtreatment, consisting of unnecessary and socially harmful limitations to fitness for work, are taken into consideration: pleural plaques, alterations of the intervertebral discs, "small airways disease", sub-clinical hearing impairment. In Italy the National Insurance for occupational diseases (INAIL) regularly recognizes less than 50% of the notified diseases; this might suggest overdiagnosis and possibly overattribution in reporting. Physicians dealing with the diagnosis of occupational diseases are obviously requested to perform a careful, up-to-date and active investigation. When applying to the diagnosis of occupational diseases, proper logical criteria should be even antecedent to a good diagnostic technique, due to social outcome for the worker.

Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge

PubMed Central

Rosic, Tea; Kalra, Sameer; Samaan, Zainab

2016-01-01

Somatic symptom disorder (SSD) is characterised by a dysfunctional preoccupation with one or more physical symptoms. Patients with SSD often pursue excessive and unnecessary investigations, hospitalisations and treatments that significantly affect quality of life and drain healthcare resources. Thus, appropriate diagnosis and careful management are required to mitigate the patient's distress and to reduce the burden to the healthcare system. SSD is a new disorder defined in the Diagnostic and Statistical Manual Fifth Edition (DSM-5), replacing somatoform and related disorders in the DSM-4-Text Revision with diagnostic criteria that are inclusive of a broad array of presentations. This report presents a detailed clinical case of an elderly man with a history of frequent hospital visits presenting with SSD. We discuss diagnostic challenges and evidence-based management in acute inpatient as well as in outpatient settings. We also review data on healthcare utilisation associated with SSD. PMID:26759438

Theranostics in nuclear medicine practice.

PubMed

Yordanova, Anna; Eppard, Elisabeth; Kürpig, Stefan; Bundschuh, Ralph A; Schönberger, Stefan; Gonzalez-Carmona, Maria; Feldmann, Georg; Ahmadzadehfar, Hojjat; Essler, Markus

2017-01-01

The importance of personalized medicine has been growing, mainly due to a more urgent need to avoid unnecessary and expensive treatments. In nuclear medicine, the theranostic approach is an established tool for specific molecular targeting, both for diagnostics and therapy. The visualization of potential targets can help predict if a patient will benefit from a particular treatment. Thanks to the quick development of radiopharmaceuticals and diagnostic techniques, the use of theranostic agents has been continually increasing. In this article, important milestones of nuclear therapies and diagnostics in the context of theranostics are highlighted. It begins with a well-known radioiodine therapy in patients with thyroid cancer and then progresses through various approaches for the treatment of advanced cancer with targeted therapies. The aim of this review was to provide a summary of background knowledge and current applications, and to identify the advantages of targeted therapies and imaging in nuclear medicine practices.

Theranostics in nuclear medicine practice

PubMed Central

Yordanova, Anna; Eppard, Elisabeth; Kürpig, Stefan; Bundschuh, Ralph A; Schönberger, Stefan; Gonzalez-Carmona, Maria; Feldmann, Georg; Ahmadzadehfar, Hojjat; Essler, Markus

2017-01-01

The importance of personalized medicine has been growing, mainly due to a more urgent need to avoid unnecessary and expensive treatments. In nuclear medicine, the theranostic approach is an established tool for specific molecular targeting, both for diagnostics and therapy. The visualization of potential targets can help predict if a patient will benefit from a particular treatment. Thanks to the quick development of radiopharmaceuticals and diagnostic techniques, the use of theranostic agents has been continually increasing. In this article, important milestones of nuclear therapies and diagnostics in the context of theranostics are highlighted. It begins with a well-known radioiodine therapy in patients with thyroid cancer and then progresses through various approaches for the treatment of advanced cancer with targeted therapies. The aim of this review was to provide a summary of background knowledge and current applications, and to identify the advantages of targeted therapies and imaging in nuclear medicine practices. PMID:29042793

Nipple piercing may be contraindicated in male patients with chest implants.

PubMed

de Kleer, N; Cohen, M; Semple, J; Simor, A; Antonyshyn, O

2001-08-01

The authors present a man who underwent chest augmentation and nipple piercing. The patient developed chronic nipple infection, which led to unnecessary invasive diagnostic procedures, serious implant infection, and eventually urgent explantation. This unfavorable scenario illustrates the distinct features of the procedure in men, which includes close proximity of the nipple to the implant and reduced awareness by health care providers. Based on this case the authors recommend avoiding nipple piercing in men with chest implants.

Healthcare Use Patterns and Economic Burden of Chronic Musculoskeletal Pain in Children before Diagnosis.

PubMed

Tian, Frances; Guittar, Patsy; Moore-Clingenpeel, Melissa; Higgins, Gloria; Ardoin, Stacy P; Spencer, Charles H; Jones, Karla; Thomas, Bethanne; Akoghlanian, Shoghik; Bout-Tabaku, Sharon

2018-06-01

To evaluate the healthcare use and costs of amplified musculoskeletal pain syndrome (AMPS) in children before diagnosis. We performed a retrospective study in children with AMPS at a pediatric rheumatology clinic between 2010 and 2014. Data were abstracted on 80 patients after primary rheumatic diseases were excluded. Healthcare visits, medications and diagnostic testing that occurred in the years before diagnosis were collected. The Medical Expenditure Panel Survey was used to estimate visit costs. Patients were adolescent females (89%) and white (86%). The median time to diagnosis was 10.2 months. The median pain score was 6.5 and the median Childhood Health Assessment Questionnaire score was 1.1. In this cohort, 29% had at least 1 ED visit and 5% were hospitalized. All patients saw a rheumatologist and 41% had visited another specialist, typically orthopedics and sports medicine. More than one-half had at least 1 radiographic study and 21% had at least 1 magnetic resonance imaging. The total cost for office, emergency department, and hospital visits for AMPS in all 80 patients was $152 853. The mean cost per patient over the entire study period (2008-2014) was $1911 ± $3808, and 43% of costs were outpatient visits. Children with AMPS have high levels of disability and take a long time to be diagnosed. As a result, even before diagnosis, they have high levels of healthcare use, diagnostic testing, and medical costs. Early recognition of disability and quicker referral to trained subspecialists may improve the prognosis, reduce unnecessary testing, and reduce the overall costs of healthcare. Copyright © 2018. Published by Elsevier Inc.

The Diagnostic Validity of the 13C-Urea Breath Test in the Gastrectomized Patients: Single Tertiary Center Retrospective Cohort Study

PubMed Central

Kwon, Yong Hwan; Kim, Nayoung; Lee, Ju Yup; Choi, Yoon Jin; Yoon, Kichul; Yoon, Hyuk; Shin, Cheol Min; Park, Young Soo; Lee, Dong Ho

2014-01-01

Background: This study was conducted to evaluate the diagnostic validity of the 13C-urea breath test (13C-UBT) in the remnant stomach after partial gastrectomy for gastric cancer. Methods: The 13C-UBT results after Helicobacter pylori eradication therapy was compared with the results of endoscopic biopsy-based methods in the patients who have received partial gastrectomy for the gastric cancer. Results: Among the gastrectomized patients who showed the positive 13C-UBT results (≥ 2.5‰, n = 47) and negative 13C-UBT results (< 2.5‰, n = 114) after H. pylori eradication, 26 patients (16.1%) and 4 patients (2.5%) were found to show false positive and false negative results based on biopsy-based methods, respectively. The sensitivity, specificity, false positive rate, and false negative rate for the cut-off value of 2.5‰ were 84.0%, 80.9%, 19.1%, and 16.0%, respectively. The positive and negative predictive values were 44.7% and 96.5%, respectively. In the multivariate analysis, two or more H. pylori eradication therapies (odds ratio = 3.248, 95% confidence interval= 1.088–9.695, P = 0.035) was associated with a false positive result of the 13C-UBT. Conclusions: After partial gastrectomy, a discordant result was shown in the positive 13C-UBT results compared to the endoscopic biopsy methods for confirming the H. pylori status after eradication. Additional endoscopic biopsy-based H. pylori tests would be helpful to avoid unnecessary treatment for H. pylori eradication in these cases. PMID:25574466

Aortic stiffness improves the prediction of both diagnosis and severity of coronary artery disease.

PubMed

Yannoutsos, Alexandra; Ahouah, Mathieu; Dreyfuss Tubiana, Céline; Topouchian, Jirar; Safar, Michel E; Blacher, Jacques

2018-02-01

Elective coronography has low diagnostic yield for obstructive coronary artery disease (CAD). We aim to determine whether non-invasive aortic stiffness assessment improves diagnostic accuracy of CAD screening by reducing the number of false-positive results from the cardiac stress test. A cross-sectional study was conducted from January 2013 to September 2014 in our medical center. Electrocardiogram (ECG) stress test coupled with nuclear imaging was performed in 367 consecutive patients routinely followed for myocardial ischemia screening. Aortic pulse wave velocity (PWV) was assessed by applanation tonometry in the overall population. Forty-two patients underwent elective coronography because of ischemia. Theoretical PWV was calculated according to age, blood pressure and gender. The results were expressed as an index ((measured PWV-theoretical PWV)/theoretical PWV) for each patient. Ten patients presented with obstructive CAD, 16 patients had non-obstructive CAD and 16 patients had normal coronary angiography. PWV index and severity of CAD were positively correlated (P=0.001). All patients with obstructive CAD had a positive PWV index. When considering the PWV index retrospectively, the false positive results of cardiac stress test were significantly reduced (P<0.001). Twenty-three procedures may have been avoided in the present study cohort. The salient finding of this study was that in patients with known or suspected CAD, routinely followed aortic PWV index may be considered clinically useful for reducing the rate of unnecessary invasive angiographies. The clinical relevance of this individualized decision approach should be confirmed in a large-scale study. Prospective studies have the potential to evaluate the PWV index as a marker of CAD.

Performance of Thirteen Clinical Rules to Distinguish Bacterial and Presumed Viral Meningitis in Vietnamese Children

PubMed Central

Huy, Nguyen Tien; Thao, Nguyen Thanh Hong; Tuan, Nguyen Anh; Khiem, Nguyen Tuan; Moore, Christopher C.; Thi Ngoc Diep, Doan; Hirayama, Kenji

2012-01-01

Background and Purpose Successful outcomes from bacterial meningitis require rapid antibiotic treatment; however, unnecessary treatment of viral meningitis may lead to increased toxicities and expense. Thus, improved diagnostics are required to maximize treatment and minimize side effects and cost. Thirteen clinical decision rules have been reported to identify bacterial from viral meningitis. However, few rules have been tested and compared in a single study, while several rules are yet to be tested by independent researchers or in pediatric populations. Thus, simultaneous test and comparison of these rules are required to enable clinicians to select an optimal diagnostic rule for bacterial meningitis in settings and populations similar to ours. Methods A retrospective cross-sectional study was conducted at the Infectious Department of Pediatric Hospital Number 1, Ho Chi Minh City, Vietnam. The performance of the clinical rules was evaluated by area under a receiver operating characteristic curve (ROC-AUC) using the method of DeLong and McNemar test for specificity comparison. Results Our study included 129 patients, of whom 80 had bacterial meningitis and 49 had presumed viral meningitis. Spanos's rule had the highest AUC at 0.938 but was not significantly greater than other rules. No rule provided 100% sensitivity with a specificity higher than 50%. Based on our calculation of theoretical sensitivity and specificity, we suggest that a perfect rule requires at least four independent variables that posses both sensitivity and specificity higher than 85–90%. Conclusions No clinical decision rules provided an acceptable specificity (>50%) with 100% sensitivity when applying our data set in children. More studies in Vietnam and developing countries are required to develop and/or validate clinical rules and more very good biomarkers are required to develop such a perfect rule. PMID:23209715

Performance of thirteen clinical rules to distinguish bacterial and presumed viral meningitis in Vietnamese children.

PubMed

Huy, Nguyen Tien; Thao, Nguyen Thanh Hong; Tuan, Nguyen Anh; Khiem, Nguyen Tuan; Moore, Christopher C; Thi Ngoc Diep, Doan; Hirayama, Kenji

2012-01-01

Successful outcomes from bacterial meningitis require rapid antibiotic treatment; however, unnecessary treatment of viral meningitis may lead to increased toxicities and expense. Thus, improved diagnostics are required to maximize treatment and minimize side effects and cost. Thirteen clinical decision rules have been reported to identify bacterial from viral meningitis. However, few rules have been tested and compared in a single study, while several rules are yet to be tested by independent researchers or in pediatric populations. Thus, simultaneous test and comparison of these rules are required to enable clinicians to select an optimal diagnostic rule for bacterial meningitis in settings and populations similar to ours. A retrospective cross-sectional study was conducted at the Infectious Department of Pediatric Hospital Number 1, Ho Chi Minh City, Vietnam. The performance of the clinical rules was evaluated by area under a receiver operating characteristic curve (ROC-AUC) using the method of DeLong and McNemar test for specificity comparison. Our study included 129 patients, of whom 80 had bacterial meningitis and 49 had presumed viral meningitis. Spanos's rule had the highest AUC at 0.938 but was not significantly greater than other rules. No rule provided 100% sensitivity with a specificity higher than 50%. Based on our calculation of theoretical sensitivity and specificity, we suggest that a perfect rule requires at least four independent variables that posses both sensitivity and specificity higher than 85-90%. No clinical decision rules provided an acceptable specificity (>50%) with 100% sensitivity when applying our data set in children. More studies in Vietnam and developing countries are required to develop and/or validate clinical rules and more very good biomarkers are required to develop such a perfect rule.

Treatment of Angina and Microvascular Coronary Dysfunction

PubMed Central

Samim, Arang; Nugent, Lynn; Mehta, Puja K.; Shufelt, Chrisandra; Merz, C. Noel Bairey

2014-01-01

Opinion statement Microvascular coronary dysfunction (MCD) is an increasingly recognized cause of cardiac ischemia and angina, more commonly diagnosed in women. Patients with MCD present with the triad of persistent chest pain, ischemic changes on stress testing, and no obstructive coronary artery disease (CAD) on cardiac catheterization. Data from National Heart, Lung and Blood Institute (NHLBI)-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study has shown that the diagnosis of MCD is not benign, with a 2.5% annual risk of adverse cardiac events including myocardial infarction, stroke, congestive heart failure, or death. The gold standard diagnostic test for MCD is an invasive coronary reactivity test (CRT), which uses acetylcholine, adenosine, and nitroglycerin to test the endothelial dependent and independent, microvascular and macrovascular coronary function. The CRT allows for diagnostic and treatment options as well as further risk stratifying patients for future cardiovascular events. Treatment of angina and MCD should be aimed at ischemia disease management to reduce risk of adverse cardiac events, ameliorating symptoms to improve quality of life, and to decrease the morbidity from unnecessary and repeated cardiac catheterization in patients with open coronary arteries. A comprehensive treatment approach aimed at risk factor managment, including lifestyle counseling regarding smoking cessation, nutrition and physical activity should be initiated. Current pharmacotherapy for MCD can include the treatment of microvascular endothelial dysfunction (statins, angiotensin-converting enzyme inhibitor, low dose aspirin), as well as treatment for angina and myocardial ischemia (beta blockers, calcium channel blockers, nitrates, ranolazine). Additional symptom management techniques can include tri-cyclic medication, enhanced external counterpulsation, autogenic training, and spinal cord stimulation. While our current therapies are effective in the treatment of angina and MCD, large randomized outcome trials are needed to optimize strategies to improve morbidity and mortality. PMID:20842559

Secondary Signs May Improve the Diagnostic Accuracy of Equivocal Ultrasounds for Suspected Appendicitis in Children

PubMed Central

Partain, Kristin N.; Patel, Adarsh; Travers, Curtis; McCracken, Courtney; Loewen, Jonathan; Braithwaite, Kiery; Heiss, Kurt F.; Raval, Mehul V.

2016-01-01

Introduction Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improves diagnostic accuracy in equivocal US studies. Methods Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. Results 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% Confidence Interval (CI) 2.1–82.8), hyperemia (OR=2.0, 95%CI 1.5–95.5), free fluid (OR=9.8, 95%CI 3.8–25.4), and appendicolith (OR=7.9, 95%CI 1.7–37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy. Conclusion Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions. PMID:27039121

Does NGAL reduce costs? A cost analysis of urine NGAL (uNGAL) & serum creatinine (sCr) for acute kidney injury (AKI) diagnosis.

PubMed

Parikh, Amay; Rizzo, John A; Canetta, Pietro; Forster, Catherine; Sise, Meghan; Maarouf, Omar; Singer, Eugenia; Elger, Antje; Elitok, Saban; Schmidt-Ott, Kai; Barasch, Jonathon; Nickolas, Thomas L

2017-01-01

Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a sensitive and specific diagnostic test for acute kidney injury (AKI) in the Emergency Department (ED), but its economic impact has not been investigated. We hypothesized that uNGAL used in combination with serum creatinine (sCr) would reduce costs in the management of AKI in patients presenting to the ED in comparison to using sCr alone. A cost simulation model was developed for clinical algorithms to diagnose AKI based on sCr alone vs. uNGAL plus sCr (uNGAL+sCr). A cost minimization analysis was performed to determine total expected costs for patients with AKI. uNGAL test characteristics were validated with eight-hundred forty-nine patients with sCr ≥1.5 from a completed study of 1635 patients recruited from EDs at two U.S. hospitals from 2007-8. Biomarker test, AKI work-up, and diagnostic imaging costs were incorporated. For a hypothetical cohort of 10,000 patients, the model predicted that the expected costs were $900 per patient (pp) in the sCr arm and $950 in the uNGAL+sCr arm. uNGAL+sCr resulted in 1,578 fewer patients with delayed diagnosis and treatment than sCr alone (2,013 vs. 436 pts) at center 1 and 1,973 fewer patients with delayed diagnosis and treatment than sCr alone at center 2 (2,227 vs. 254 patients). Although initial evaluation costs at each center were $50 pp higher in with uNGAL+sCr, total costs declined by $408 pp at Center 1 and by $522 pp at Center 2 due to expected reduced delays in diagnosis and treatment. Sensitivity analyses confirmed savings with uNGAL + sCr for a range of cost inputs. Using uNGAL with sCr as a clinical diagnostic test for AKI may improve patient management and reduce expected costs. Any cost savings would likely result from avoiding delays in diagnosis and treatment and from avoidance of unnecessary testing in patients given a false positive AKI diagnosis by use of sCr alone.

Managing acute abdominal pain in pediatric patients: current perspectives

PubMed Central

Hijaz, Nadia M; Friesen, Craig A

2017-01-01

Acute abdominal pain in pediatric patients has been a challenge for providers because of the nonspecific nature of symptoms and difficulty in the assessment and physical examination in children. Although most children with acute abdominal pain have self-limited benign conditions, pain may be a manifestation of an urgent surgical or medical condition where the biggest challenge is making a timely diagnosis so that appropriate treatment can be initiated without any diagnostic delays that increase morbidity. This is weighed against the need to decrease radiation exposure and avoid unnecessary operations. Across all age groups, there are numerous conditions that present with abdominal pain ranging from a very simple viral illness to a life-threatening surgical condition. It is proposed that the history, physical examination, laboratory tests, and imaging studies should initially be directed at differentiating surgical versus nonsurgical conditions both categorized as urgent versus nonurgent. The features of the history including patient’s age, physical examination focused toward serious conditions, and appropriate tests are highlighted in the context of making these differentiations. Initial testing and management is also discussed with an emphasis on making use of surgeon and radiologist consultation and the need for adequate follow-up and reevaluation of the patient. PMID:29388612

Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost.

PubMed

Pellet, Andrew C; Erten, Mujde Z; James, Ted A

2016-06-01

Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients. A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded. From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905. Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost. Copyright © 2015 Elsevier Inc. All rights reserved.

Evaluation of the automated urine particle analyzer UF-1000i screening for urinary tract infection in nonpregnant women.

PubMed

Dai, Qingkai; Jiang, Yongmei; Shi, Hua; Zhou, Wei; Zhou, Shengjie; Yang, Hui

2014-01-01

Urinary tract infection (UTI) is a widespread disease in women. Urine culture is still the "gold standard" diagnostic test for UTI, but most of them are negative. To reduce unnecessary culture, we evaluated the automated urine particle analyzer UF-1000i screening for UTI in nonpregnant women. The urine specimens submitted to our laboratory were submitted for culture and tested by the Sysmex UF-1000i. Bacteria and white blood cell (WBC) counts were compared to standard urine culture results to assess the best cutoff values. In this study, 272 urine samples were included, of which 98 (36.0%) were culture positive with a bacterial cutoff value of 10 x 10(5) CFU/mL. A combination of bacterial (> 95/microL) and/or WBC count (> 24/microL) provided the best screening for UTI, with a sensitivity of 0.99 and a specificity of 0.82 compared with the urine culture. Sysmex UF-1000i could be used as a screening test for UTI in nonpregnant women. According to the distribution and range of the bacterial scattergram, we could primarily identify and differentiate between Gram-negative and Gram-positive bacteria.

Acute kidney injury in a child: A case of Munchausen syndrome by proxy.

PubMed

Mantan, Mukta; Dhingra, Dhulika; Gupta, Aditi; Sethi, Gulshan Rai

2015-11-01

Renal and urologic problems in pediatric condition falsification (PCF) or Munchausen by proxy (MSP) can result in serious diagnostic dilemma. Symptoms of hematuria, pyuria and recurrent urinary tract infections have occasionally been described. However, MSP presenting as azotemia has not been previously reported. We describe the case of an unfortunate boy who had to undergo unnecessary hemodialysis for persistent hyperkalemia and azotemia before a final diagnosis of the falsification of investigations by the parents was made.

[Non-epileptic paroxysmal sleep disorders].

PubMed

Malagón-Valdez, Jorge

2013-09-06

Non-epileptic paroxysmal disorders during sleep are a great challenge for the clinician. It is important to know the various clinical manifestations for appropriate differential diagnosis, since alterations in sleep, mostly motor, are part of these disorders. Our paper describes the normal sleep stages and electroencephalographic characteristics and polysomnography basic data. The confusions especially with nocturnal frontal lobe epilepsy are frequent and cause unnecessary drugs administered, the emotional burden of the parents or caretakers, which is the diagnosis of epilepsy. We discuss the possible causes of diagnostic errors.

Genetic disorders with heterotopic ossificans

PubMed Central

Sankar, Ruthiramurthy; Gowrishankar, Kalpana; Viswanathan, Saraswati

2015-01-01

Fibrodysplasia ossificans progressiva (FOP) and progressive ossific heteroplasia (POH) are rare genetic disorders characterized by heterotopic bone formation leading to progressive loss of mobility and function. We report three cases of these rare disorders (two cases of FOP and one case of POH), which were clinically diagnosed and underwent genetic analysis. The aim of this report is to highlight the clinical features and the differences between these two conditions. We would also like to emphasize on the morbidity that can arise from unnecessary invasive investigations for diagnostic purposes. PMID:26015640

Evaluation of a Commercial Field Test to Detect African Swine Fever.

PubMed

Cappai, Stefano; Loi, Federica; Coccollone, Annamaria; Cocco, Manuele; Falconi, Caterina; Dettori, Giovanna; Feliziani, Francesco; Sanna, Maria Luisa; Oggiano, Annalisa; Rolesu, Sandro

2017-07-01

African swine fever (ASF) is one of the most important and complex infectious diseases affecting pigs ( Sus scrofa ). The disease has been present in Sardinia, Italy, since 1978. Factors influencing the presence of the disease on the island are the presence of illegally bred pigs, uncontrolled movements of animals, and local traditions. Implementation of public health programs is essential for controlling ASF. The use of new diagnostic techniques on both wild boar (WB) and illegally bred pigs would provide tools for faster and more inexpensive control of the disease. We evaluated a commercial serological test kit (Pen-side [PS]) for use in the field. We sampled 113 hunter-harvested WB during the 2014-15 season, collecting blood and lung samples to conduct serological analyses and to screen for the ASF virus. Although the sensitivity (81.8%) and specificity (95.9%) of tests performed in the field were reduced compared to the same test in laboratory, they nevertheless allowed for rapid diagnosis and reduced unnecessary carcass destruction. The test, conducted in the field, was less expensive than in the laboratory and required less manpower. Therefore, we conclude that the combined use of antibody PS test and antigen PS test may be a valuable emergency management method during an outbreak as well as a useful tool for conducting regular monitoring activities as a preventive policy.

Diagnostic accuracy of ultrasonography in detection of blunt abdominal trauma and comparison of early and late ultrasonography 24 hours after trauma.

PubMed

Feyzi, Ali; Rad, Masoud Pezeshki; Ahanchi, Navid; Firoozabadi, Jalil

2015-01-01

Despite the advantages of ultrasound scan, its use as a screening tool in blunt abdominal trauma is controversial. The aim of this study was to evaluate the diagnostic value of early and late ultrasound in patients with blunt abdominal trauma (BAT). In this study which was performed in a level I trauma center, firstly, 2418 patients with BAT had ultrasound (US) examination by two trauma expert radiologists. Results were compared with the best available gold standards such as laparotomy, CT, repeated ultrasound or clinical course follow-up. Then, 400 patients with BAT were examined by a trained residency student. In the first phase, sensitivity, specificity, negative predictive value, positive predictive value and accuracy of ultrasound were 97%, 98.1%, 99.7%, 83% and 98% respectively. In the second phase, they were 97.3%, 97.2%, 97.7%, 96.8% and 97.3% for the early and 98.5%, 97.6%, 98.5%, 97.5% and 98% for the late ultrasound respectively. Results obtained from this study indicate that negative ultrasound findings associated with negative clinical observation virtually exclude abdominal injury, and confirmation by performing other tests is unnecessary. High sensitivity and negative predictive value is achieved if ultrasound is performed by expert trauma radiologist.

Molecular diagnosis of patients with epilepsy and developmental delay using a customized panel of epilepsy genes.

PubMed

Ortega-Moreno, Laura; Giráldez, Beatriz G; Soto-Insuga, Victor; Losada-Del Pozo, Rebeca; Rodrigo-Moreno, María; Alarcón-Morcillo, Cristina; Sánchez-Martín, Gema; Díaz-Gómez, Esther; Guerrero-López, Rosa; Serratosa, José M

2017-01-01

Pediatric epilepsies are a group of disorders with a broad phenotypic spectrum that are associated with great genetic heterogeneity, thus making sequential single-gene testing an impractical basis for diagnostic strategy. The advent of next-generation sequencing has increased the success rate of epilepsy diagnosis, and targeted resequencing using genetic panels is the a most cost-effective choice. We report the results found in a group of 87 patients with epilepsy and developmental delay using targeted next generation sequencing (custom-designed Haloplex panel). Using this gene panel, we were able to identify disease-causing variants in 17 out of 87 (19.5%) analyzed patients, all found in known epilepsy-associated genes (KCNQ2, CDKL5, STXBP1, SCN1A, PCDH19, POLG, SLC2A1, ARX, ALG13, CHD2, SYNGAP1, and GRIN1). Twelve of 18 variants arose de novo and 6 were novel. The highest yield was found in patients with onset in the first years of life, especially in patients classified as having early-onset epileptic encephalopathy. Knowledge of the underlying genetic cause provides essential information on prognosis and could be used to avoid unnecessary studies, which may result in a greater diagnostic cost-effectiveness.

Diagnostic value of coustic radiation force impulse for BI-RADS category 4 breast lesions of different sizes.

PubMed

Wu, Rong

2018-04-14

To determine the diagnostic value of combined conventional ultrasound (US) and acoustic radiation force impulse (ARFI) imaging for the differential diagnosis of BI-RADS category 4 breast lesions of different sizes. From April 2013 to January 2015, 283 patients (with a total of 292 breast lesions) who underwent US and ARFI examination were included in this retrospective study. The SWV for the lesion and adjacent normal breast tissue were measured and the SWV ratio was calculated. VTI grade was also assessed. The lesions were separated into three groups on the basis of size, and two combinations of ARFI parameters (SWV + VTI and SWV ratio + VTI) were applied to reassess the BI-RADS categories. Diagnoses were confirmed by pathological examination after biopsy or surgery. ROC analysis was performed to assess the diagnostic efficiency of each method. The Z test was used to compare the difference between AUC of the two methods. Significant improvement was seen in the diagnostic performance of US with the use of the ARFI parameters SWV + VTI (77/179 [43.0%] of BI-RADS category 4A breast lesions were downgraded) and SWV ratio + VTI (64/179 [35.8%] of BI-RADS category 4A breast lesions were downgraded, including two malignant cases that were misdiagnosed as benign) (P < 0.01). The difference between the performances of the two combinations-SWV + VTI and SWV ratio + VTI-was significant only in breast lesions <10 mm in size, where the AUC of SWV ratio + VTI was significantly greater than the AUC of SWV + VTI (0.929 vs. 0.874; P < 0.01). Combination of US with ARFI can improve diagnostic performance and help avoid unnecessary biopsy in BI-RADS category 4 breast lesions. The combination of SWV ratio + VTI can improve BI-RADS classification of small lesions (<10 mm size).

[Epilepsy-new diagnostic tools, old drugs? : Therapeutic consequences of epilepsy genetics].

PubMed

Tacke, M; Neubauer, B A; Gerstl, L; Roser, T; Rémi, J; Borggraefe, I

2017-12-01

Recent advances in the field of epilepsy genetics have led to an increased fraction of patients with epilepsies where the etiology of the disease could be identified. Nevertheless, there is some criticism regarding the use of epilepsy genetics because in many cases the identification of a pathogenetic mutation does not lead to an adaptation of therapy or to an improved prognosis. In addition, the interpretation of genetic results might be complicated due to the considerable numbers of variants of unclear significance. This publication presents the arguments in favour of a broad use of genetic investigations for children with epilepsies. Several diseases where a genetic diagnosis does in fact have direct therapeutic consequences are mentioned. In addition, the indirect impact of an established etiology, encompassing the avoidance of unnecessary diagnostic measures, possibility of genetic counselling, and the easing of the psychologic burden for the caregivers, should not be underestimated. The arguments in favour of broad genetic diagnostics prevail notwithstanding the lack of relevant new developments regarding the therapy.

Subacute sclerosing panencephalitis (SSPE) presenting as acute disseminated encephalomyelitis in a child.

PubMed

Goraya, Jatinder; Marks, Harold; Khurana, Divya; Legido, Agustin; Melvin, Joseph

2009-07-01

Subacute sclerosing panencephalitis (SSPE) typically presents with progressive mental deterioration, behavioral changes, and myoclonic jerks. Atypical presentations are not unknown and may result in diagnostic delays. A 9-year-old girl presented with poor balance and ataxia following an episode of upper respiratory tract infection. Neurological examination revealed mild hemiparesis and ataxia. Brain magnetic resonance imaging revealed scattered areas of T2 and fluid-attenuated inversion recovery hyperintensities in the white matter consistent with acute disseminated encephalomyelitis. Despite treatment with intravenous methylprednisolone, intravenous immunoglobulins, and plasmapheresis, progressive neurological worsening occurred. Later during the course of her illness, subacute sclerosing panencephalitis was suspected from the appearance of burst-suppression pattern on electroencephalogram, and the diagnosis confirmed by elevated titers of measles antibodies in cerebrospinal fluid. Physicians taking care of children need to be aware of atypical presentations of subacute sclerosing panencephalitis and must have a high index of suspicion to prevent diagnostic delays and avoid unnecessary diagnostic and therapeutic interventions.

Understanding the impact of genetic testing for inherited retinal dystrophy

PubMed Central

Combs, Ryan; McAllister, Marion; Payne, Katherine; Lowndes, Jo; Devery, Sophie; Webster, Andrew R; Downes, Susan M; Moore, Anthony T; Ramsden, Simon; Black, Graeme; Hall, Georgina

2013-01-01

The capability of genetic technologies is expanding rapidly in the field of inherited eye disease. New genetic testing approaches will deliver a step change in the ability to diagnose and extend the possibility of targeted treatments. However, evidence is lacking about the benefits of genetic testing to support service planning. Here, we report qualitative data about retinal dystrophy families' experiences of genetic testing in United Kingdom. The data were part of a wider study examining genetic eye service provision. Twenty interviewees from families in which a causative mutation had been identified by a genetic eye clinic were recruited to the study. Fourteen interviewees had chosen to have a genetic test and five had not; one was uncertain. In-depth telephone interviews were conducted allowing a thorough exploration of interviewees' views and experiences of the benefits of genetic counselling and testing. Transcripts were analysed using thematic analysis. Both affected and unaffected interviewees expressed mainly positive views about genetic testing, highlighting benefits such as diagnostic confirmation, risk information, and better preparation for the future. Negative consequences included the burden of knowledge, moral dilemmas around reproduction, and potential impact on insurance. The offer of genetic testing was often taken up, but was felt unnecessary in some cases. Interviewees in the study reported many benefits, suggesting genetic testing should be available to this patient group. The benefits and risks identified will inform future evaluation of models of service delivery. This research was part of a wider study exploring experiences of families with retinal dystrophy. PMID:23403902

Understanding the impact of genetic testing for inherited retinal dystrophy.

PubMed

Combs, Ryan; McAllister, Marion; Payne, Katherine; Lowndes, Jo; Devery, Sophie; Webster, Andrew R; Downes, Susan M; Moore, Anthony T; Ramsden, Simon; Black, Graeme; Hall, Georgina

2013-11-01

The capability of genetic technologies is expanding rapidly in the field of inherited eye disease. New genetic testing approaches will deliver a step change in the ability to diagnose and extend the possibility of targeted treatments. However, evidence is lacking about the benefits of genetic testing to support service planning. Here, we report qualitative data about retinal dystrophy families' experiences of genetic testing in United Kingdom. The data were part of a wider study examining genetic eye service provision. Twenty interviewees from families in which a causative mutation had been identified by a genetic eye clinic were recruited to the study. Fourteen interviewees had chosen to have a genetic test and five had not; one was uncertain. In-depth telephone interviews were conducted allowing a thorough exploration of interviewees' views and experiences of the benefits of genetic counselling and testing. Transcripts were analysed using thematic analysis. Both affected and unaffected interviewees expressed mainly positive views about genetic testing, highlighting benefits such as diagnostic confirmation, risk information, and better preparation for the future. Negative consequences included the burden of knowledge, moral dilemmas around reproduction, and potential impact on insurance. The offer of genetic testing was often taken up, but was felt unnecessary in some cases. Interviewees in the study reported many benefits, suggesting genetic testing should be available to this patient group. The benefits and risks identified will inform future evaluation of models of service delivery. This research was part of a wider study exploring experiences of families with retinal dystrophy.

Long-term wireless pH monitoring of the distal esophagus: prolonging the test beyond 48 hours is unnecessary and may be misleading.

PubMed

Capovilla, G; Salvador, R; Spadotto, L; Voltarel, G; Pesenti, E; Perazzolo, A; Nicoletti, L; Merigliano, S; Costantini, M

2017-10-01

Wireless pH monitoring of the esophagus has been widely used to detect GERD for more than a decade. It is generally well tolerated and accepted by patients, but it is still unclear whether prolonging a recording beyond the usual 48 hours can improve the test's diagnostic value. The aim of this study is to examine the diagnostic yield of 96-hour pH monitoring vis-à-vis 24- and 48-hour tests, and to ascertain whether any gain in diagnostic terms was of genuine clinical utility. Patients with suspected GERD underwent 4-day PPI-off wireless pH monitoring of the distal esophagus. The capsule was inserted under endoscopic control, 6 cm above the squamocolumnar junction. Average acid exposure time was calculated after 24, 48, and 96 hours of recording. Ninety-nine patients completed the 96 hour test, and formed the study sample. The wireless test method was used in 42 patients (42.4%) unable to tolerate the traditional pH-monitoring catheter, and in 57 (57.6%) with a previous negative pH study despite symptoms suggestive of GERD. On complete analysis, 47 patients (47.5%) had a pathological test result: 19 patients within the first 24 hours (19.2%, 24 hour group); another 16 after 48 hours (+16.2%, 48 hour group), and a further 12 (+12.1%, 96 hour group) only after 96 hours of monitoring. All 47 patients with an abnormal acid exposure were offered and accepted surgery (10 patients) or medical therapy (37 patients). Clinical follow-up was obtained in all patients with a positive Bravo test result after a median 67 months (IQR: 38-98) using a validated symptom questionnaire. A good outcome after fundoplication or medical therapy was achieved in 73.7% of patients in the 24 hour group, in 62.5% of those in the 48 hour group, and in only 25% of those in the 96 hour group, P = 0.02. Long-term wireless pH monitoring enables an increase in the diagnostic yield over traditional 24- and 48-hour pH studies, but prolonging the test may constitute an unwanted bias and prompt the recruitment of more complex patients, in whom the outcome of surgical or medical therapy may prove less than satisfactory. These findings should be taken into account when establishing the guidelines for assessing GERD with such long-term pH monitoring methods. © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The pediatrician's role in the diagnosis and management of food allergy.

PubMed

Lau, Claudia H; Gupta, Ruchi S

2013-07-01

CME EDUCATIONAL OBJECTIVES 1. Recognize the signs and symptoms of food allergy versus food intolerance. 2. Review currently available diagnostic testing modalities for food allergy and their applicability in the pediatric outpatient setting. 3. Review appropriate management practices for pediatricians, including prescription of medications, counseling of families, and referrals to keep children safe. Food allergy is a rapidly increasing and potentially life-threatening health concern in the United States. Given the ubiquity of food in our society and the absence of a cure, it is crucial that families receive proper guidance and medication to keep children safe. The pediatrician plays a key role to this end as he or she is often the first, and sometimes the only physician, these children can access. Accordingly, pediatricians must be equipped to recognize, manage, and evaluate food allergies over time while preventing unnecessary avoidance. This review provides practical translation of guidelines into recommended practices that are most pertinent to pediatricians. Copyright 2013, SLACK Incorporated.

Reversal deterioration of renal function accompanied with primary hypothyrodism.

PubMed

Dragović, Tamara

2012-02-01

Hypothyroidism is often accompanied with decline of kidney function, or inability to maintain electrolyte balance. These changes are usually overlooked in everyday practice. Early recognition of this association eliminates unnecessary diagnostic procedures that postpone the adequate treatment. Two patients with elevated serum creatinine levels due to primary autoimmune hypothyroidism, with complete recovery of creatinine clearance after thyroid hormone substitution therapy are presented. The first patient was a young male whose laboratory tests suggested acute renal failure, and the delicate clinical presentation of reduced thyroid function. The second patient was an elderly woman with a history of a long-term signs and symptoms attributed to ageing, including the deterioration of renal function, with consequently delayed diagnosis of hypothyroidism. Serum thyrotropin and thyroxin levels measurement should be done in all cases of renal failure with undefined renal desease, even if the typical clinical presentation of hypothyroidism is absent. Thyroid hormone assays sholud also be performed in all patients with chronic kidney disease whose kidney function is rapidly worsening.

Transfusion-associated cytomegalovirus mononucleosis.

PubMed Central

Lerner, P I; Sampliner, J E

1977-01-01

Transfusion-associated cytomegalovirus mononucleosis is generally considered only as a complication of extracorporeal circulation following cardiac surgery. Three cases following trauma were recognized in less than one year. Both massive and limited volume blood transfusions were involved. Hectic fever was a characteristic feature in these otherwise remarkably asymptomatic individuals, without the classic features of heterophile-positive infectious mononucleosis. Since the illness developed several weeks into the post-operative period after extensive thoracic or abdominal trauma surgery, the presence of an undrained abscess was naturally the major diagnostic concern. Atypical lymphocytosis, markers of altered immunity (cold agglutinins, rheumatoid factor) and moderate hepatic dysfunction were important laboratory clues. In one case, focal isotope defects in the spleen scan misleadingly suggested a septic complication. A false-positive monospot test initially obscured the correct serologic diagnosis in the same patient. Failure to consider this selflimited viral infection may be a critical factor leading to unnecessary surgery. Other viral agents capable of eliciting a similar syndrome are cited. Images Fig. 1. PMID:190955

A Case of Munchausen Syndrome Presenting with Hematemesis: A Case Report

PubMed Central

Aadil, Muhammad; Faraz, Aniqa; Anwar, Muhammad Jahanzaib; Nasir, Usama; Akhlaq, Anum

2017-01-01

Munchausen syndrome (MS) was first reported in 1951 by Richard Alan John Asher as a factitious disorder. It is a condition in which the patient intentionally produces symptoms to assume a sick role and gain medical attention. Underdiagnosis of this disorder results in the unnecessary use of medical resources, i.e. unnecessary medical tests and evaluations. This makes it one of the most challenging diagnosis in any medical set up. We present this rare case of a patient with chronic factitious disorder who presented to the emergency with hematemesis. The patient was successfully treated with psychotherapy with no recurrence. It is the need of the hour to create awareness amongst the medical and nonmedical population about factitious disorders so that they can easily be diagnosed and treated with efficiency. Further research is needed to find the risks leading to this syndrome and discover the cultural and social aspects of this disease, which may help us explore treatment strategies and avoid unnecessary tests and treatment.​ PMID:28979830

Diagnostic needle arthroscopy and the economics of improved diagnostic accuracy: a cost analysis.

PubMed

Voigt, Jeffrey D; Mosier, Michael; Huber, Bryan

2014-10-01

Hundreds of thousands of surgical arthroscopy procedures are performed annually in the United States (US) based on MRI findings. There are situations where these MRI findings are equivocal or indeterminate and because of this clinicians commonly perform the arthroscopy in order not to miss pathology. Recently, a less invasive needle arthroscopy system has been introduced that is commonly performed in the physician office setting and that may help improve the accuracy of diagnostic findings. This in turn may prevent unnecessary follow-on arthroscopy procedures from being performed. The purpose of this analysis is to determine whether the in-office diagnostic needle arthroscopy system can provide cost savings by reducing unnecessary follow on arthroscopy procedures. Data obtained from a recent trial and from a systematic review were used in comparing the accuracy of MRI and VisionScope needle arthroscopy (VSI) with standard arthroscopy (gold standard). The resultant false positive and false negative findings were then used to evaluate the costs of follow-on procedures. These differences were then modeled for the US patient population diagnosed and treated for meniscal knee pathology (most common disorder) to determine if a technology such as VSI could save the US healthcare system money. Data on surgical arthroscopy procedures in the US for meniscal knee pathology were used (calendar year [CY] 2010). The costs of performing diagnostic and surgical arthroscopy procedures (using CY 2013 Medicare reimbursement amounts), costs associated with false negative findings, and the costs for treating associated complications arising from diagnostic and therapeutic arthroscopy procedures were assessed. In patients presenting with medial meniscal pathology (International Classification of Diseases, 9th edition, Clinical Modification [ICD9CM] diagnosis 836.0), VSI in place of MRI (standard of care) resulted in a net cost savings to the US system of US$115-US$177 million (CY 2013) (use of systematic review and study data, respectively). In patients presenting with lateral meniscus pathology (ICD9CM 836.1), VSI in place of MRI cost the healthcare system an additional US$14-US$97 million (CY 2013). Overall aggregate savings for meniscal (lateral plus medial) pathology were identified in representative care models along with more appropriate care as fewer patients were exposed to higher risk surgical procedures. Since in-office arthroscopy is significantly more accurate, patients can be treated more appropriately and the US healthcare system can save money, most especially in medial meniscal pathology.

Mucinous Cystadenocarcinoma of the Breast: Report of 2 Cases Including One With Long-Term Local Recurrence.

PubMed

Nayak, Anupma; Bleiweiss, Ira J; Dumoff, Kimberly; Bhuiya, Tawfiqul A

2018-05-01

Primary mucinous cystadenocarcinoma (MCA) of breast is an exceedingly rare tumor with histologic resemblance to MCA arising in ovary, pancreas, and gastrointestinal tract. In this article, we present 2 additional cases of MCA of breast, one highlighting the diagnostic challenges of a rare entity that may potentially lead to unnecessary chemotherapy and the second case presenting with recurrence after 8 years of primary surgical excision defying the indolent behavior reported in the literature. To our knowledge, this is the first reported instance of such behavior.

Tattoo pigment in axillary lymph node mimicking calcification of breast cancer

PubMed Central

Matsika, Admire; Srinivasan, Bhuvana; Gray, Janet Meryl; Galbraith, Christine Ruth

2013-01-01

A tattoo is defined as the intentional or accidental deposit of pigment into the skin. The phenomenon of skin tattooing is on the rise worldwide and complications of tattooing are increasingly being recognised in diagnostic and clinical medicine. We describe a case of calcification-like changes on mammography resembling that of breast malignancy as a result of tattoo pigment deposition in an axillary lymph node. Recognition of such changes in routine breast screening is crucial to avoid further unnecessary invasive investigations and surgery in such patients. PMID:23929611

Through the looking glass: Basics and principles of reflectance confocal microscopy.

PubMed

Que, Syril Keena T; Fraga-Braghiroli, Naiara; Grant-Kels, Jane M; Rabinovitz, Harold S; Oliviero, Margaret; Scope, Alon

2015-08-01

Reflectance confocal microscopy (RCM) offers high-resolution, noninvasive skin imaging and can help avoid obtaining unnecessary biopsy specimens. It can also increase efficiency in the surgical setting by helping to delineate tumor margins. Diagnostic criteria and several RCM algorithms have been published for the differentiation of benign and malignant neoplasms. We provide an overview of the basic principles of RCM, characteristic RCM features of normal skin and cutaneous neoplasms, and the limitations and future directions of RCM. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Unnecessary antiretroviral treatment switches and accumulation of HIV resistance mutations; two arguments for viral load monitoring in Africa.

PubMed

Sigaloff, Kim C E; Hamers, Raph L; Wallis, Carole L; Kityo, Cissy; Siwale, Margaret; Ive, Prudence; Botes, Mariette E; Mandaliya, Kishor; Wellington, Maureen; Osibogun, Akin; Stevens, Wendy S; van Vugt, Michèle; de Wit, Tobias F Rinke

2011-09-01

This study aimed to investigate the consequences of using clinicoimmunological criteria to detect antiretroviral treatment (ART) failure and guide regimen switches in HIV-infected adults in sub-Saharan Africa. Frequencies of unnecessary switches, patterns of HIV drug resistance, and risk factors for the accumulation of nucleoside reverse transcriptase inhibitor (NRTI)-associated mutations were evaluated. Cross-sectional analysis of adults switching ART regimens at 13 clinical sites in 6 African countries was performed. Two types of failure identification were compared: diagnosis of clinicoimmunological failure without viral load testing (CIF only) or CIF with local targeted viral load testing (targeted VL). After study enrollment, reference HIV RNA and genotype were determined retrospectively. Logistic regression assessed factors associated with multiple thymidine analogue mutations (TAMs) and NRTI cross-resistance (≥2 TAMs or Q151M or K65R/K70E). Of 250 patients with CIF switching to second-line ART, targeted VL was performed in 186. Unnecessary switch at reference HIV RNA <1000 copies per milliliter occurred in 46.9% of CIF only patients versus 12.4% of patients with targeted VL (P < 0.001). NRTI cross-resistance was observed in 48.0% of 183 specimens available for genotypic analysis, comprising ≥2 TAMs (37.7%), K65R (7.1%), K70E (3.3%), or Q151M (3.3%). The presence of NRTI cross-resistance was associated with the duration of ART exposure and zidovudine use. Clinicoimmunological monitoring without viral load testing resulted in frequent unnecessary regimen switches. Prolonged treatment failure was indicated by extensive NRTI cross-resistance. Access to virological monitoring should be expanded to prevent inappropriate switches, enable early failure detection and preserve second-line treatment options in Africa.

Development of Multiplex Reverse Transcription-Polymerase Chain Reaction for Simultaneous Detection of Influenza A, B and Adenoviruses

PubMed Central

Nakhaie, Mohsen; Soleimanjahi, Hoorieh; Mollaie, Hamid Reza; Arabzadeh, Seyed Mohamad Ali

2018-01-01

Background and objective: Millions of people in developing countries lose their lives due to acute respiratory infections, such as Influenza A & B and Adeno viruses. Given the importance of rapid identification of the virus, in this study the researchers attempted to design a method that enables detection of influenza A, B, and adenoviruses, quickly and simultaneously. The Multiplex RT PCR method was the preferred method for the detection of influenza A, B, and adenoviruses in clinical specimens because it is rapid, sensitive, specific, and more cost-effective than alternative methods Methods: After collecting samples from patients with respiratory disease, virus genome was extracted, then Monoplex PCR was used on positive samples and Multiplex RT-PCR on clinical specimens. Finally, by comparing the bands of these samples, the type of virus in the clinical samples was determined. Results: Performing Multiplex RT-PCR on 50 samples of respiratory tract led to following results; flu A: 12.5%, fluB: 50%, adeno: 27.5%, negative: 7.5%, and 2.5% contamination. Conclusion: Reverse transcription-multiplex Polymerase Chain Reaction (PCR) technique, a rapid diagnostic tool, has potential for high-throughput testing. This method has a significant advantage, which provides simultaneous amplification of numerous viruses in a single reaction. This study concentrates on multiplex molecular technologies and their clinical application for the detection and quantification of respiratory pathogens. The improvement in diagnostic testing for viral respiratory pathogens effects patient management, and leads to more cost-effective delivery of care. It limits unnecessary antibiotic use and improves clinical management by use of suitable treatment. PMID:29731796

Respiratory Syncytial Virus Bronchiolitis in Children.

PubMed

Smith, Dustin K; Seales, Sajeewane; Budzik, Carol

2017-01-15

Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause of this infection. RSV is transmitted through contact with respiratory droplets either directly from an infected person or self-inoculation by contaminated secretions on surfaces. Patients with RSV bronchiolitis usually present with two to four days of upper respiratory tract symptoms such as fever, rhinorrhea, and congestion, followed by lower respiratory tract symptoms such as increasing cough, wheezing, and increased respiratory effort. In 2014, the American Academy of Pediatrics updated its clinical practice guideline for diagnosis and management of RSV bronchiolitis to minimize unnecessary diagnostic testing and interventions. Bronchiolitis remains a clinical diagnosis, and diagnostic testing is not routinely recommended. Treatment of RSV infection is mainly supportive, and modalities such as bronchodilators, epinephrine, corticosteroids, hypertonic saline, and antibiotics are generally not useful. Evidence supports using supplemental oxygen to maintain adequate oxygen saturation; however, continuous pulse oximetry is no longer required. The other mainstay of therapy is intravenous or nasogastric administration of fluids for infants who cannot maintain their hydration status with oral fluid intake. Educating parents on reducing the risk of infection is one of the most important things a physician can do to help prevent RSV infection, especially early in life. Children at risk of severe lower respiratory tract infection should receive immunoprophylaxis with palivizumab, a humanized monoclonal antibody, in up to five monthly doses. Prophylaxis guidelines are restricted to infants born before 29 weeks' gestation, infants with chronic lung disease of prematurity, and infants and children with hemodynamically significant heart disease.

Emergency physician perceptions of shared decision-making.

PubMed

Kanzaria, Hemal K; Brook, Robert H; Probst, Marc A; Harris, Dustin; Berry, Sandra H; Hoffman, Jerome R

2015-04-01

Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated. As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM. A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose." Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation. © 2015 by the Society for Academic Emergency Medicine.

[The diagnostic value of cine-MR imaging in diseases of great vessels].

PubMed

Sasaki, S; Yoshida, H; Matsui, Y; Sakuma, M; Yasuda, K; Tanabe, T; Chouji, H

1990-02-01

The diagnostic value of cine magnetic resonance imaging (cine-MRI) was evaluated in 10 patients with disease of great vessels. The parameters necessary to decide the appropriate treatment, such as presence and extension of intimal flap, DeBakey type classification, identification of the entry, differentiation between true and false lumen, and between thrombosis and slow flow were demonstrated in all patients with dissecting aortic aneurysm. However, abdominal aortic branches could not be demonstrated enough by cine-MRI, therefore conventional AOG was necessary to choose the operative procedure in these cases. In patients with thoracic aortic aneurysm (TAA), cine-MRI was valuable in demonstrating both blood flow and thrombus in the lumen of aneurysm, and AOG was thought to be unnecessary in most cases. Cine-MRI is a promising new technique for the evaluation of diseases of great vessels.

Reducing duplicate testing: a comparison of two clinical decision support tools.

PubMed

Procop, Gary W; Keating, Catherine; Stagno, Paul; Kottke-Marchant, Kandice; Partin, Mary; Tuttle, Robert; Wyllie, Robert

2015-05-01

Unnecessary duplicate laboratory testing is common and costly. Systems-based means to avert unnecessary testing should be investigated and employed. We compared the effectiveness and cost savings associated with two clinical decision support tools to stop duplicate testing. The Hard Stop required telephone contact with the laboratory and justification to have the duplicate test performed, whereas the Smart Alert allowed the provider to bypass the alert at the point of order entry without justification. The Hard Stop alert was significantly more effective than the Smart Alert (92.3% vs 42.6%, respectively; P < .0001). The cost savings realized per alert activation was $16.08/alert for the Hard Stop alert vs $3.52/alert for the Smart Alert. Structural and process changes that require laboratory contact and justification for duplicate testing are more effective than interventions that allow providers to bypass alerts without justification at point of computerized physician order entry. Copyright© by the American Society for Clinical Pathology.

Targeting the initial investigation and management in cases of acute pulmonary embolism.

PubMed

Moore, Nicholas; Hawkins, Peter

2013-01-01

It was noted by consultants in our hospital that the early investigation of suspected pulmonary embolism (PE) lacked structure. This was causing delays in definitive diagnosis and early management. The resulting unnecessary use of investigation was also wasting resources. In particular, the inappropriate use of serum d-dimer tests was causing concern. The National Institute of Clinical Excellence (NICE) guidelines recommend use of the 2-level Well's score to target investigation in suspected PE. A baseline audit against the NICE guideline revealed that Well's scores were rarely used (only calculated in 12% of cases) and confirmed the suspicion that early investigation was poorly targeted. This project intervened using educational talks promoting the use of Well's scores in cases of suspected PE. Well's score proformas were placed in the emergency department and emergency assessment unit for reference. Their availability was advertised. This significantly increased the use of Well's scores (46% vs 11%, p<0.001). Fewer patients underwent unnecessary d-dimer measurements in cases of likely PE (65% vs 86%). Initial investigation was more targeted in cases where a Well's score had been calculated than in cases without a Well's score. For example, significantly fewer unnecessary d-dimer tests were performed in these cases (45% vs 100%, p<0.05). The cost of unnecessary investigation in suspected PE is not only significant financially but also in the resulting delay in definitive diagnosis and management for the patient. The simple intervention used here was effective in addressing this problem.

Economic evaluation of point-of-care testing in the remote primary health care setting of Australia's Northern Territory.

PubMed

Spaeth, Brooke A; Kaambwa, Billingsley; Shephard, Mark Ds; Omond, Rodney

2018-01-01

To determine the cost-effectiveness of utilizing point-of-care testing (POCT) on the Abbott i-STAT device as a support tool to aid decisions regarding the emergency medical retrievals of patients at remote health centers in the Northern Territory (NT) of Australia. A decision analytic simulation model-based economic evaluation was conducted using data from patients presenting with three common acute conditions (chest pain, chronic renal failure due to missed dialysis session(s), and acute diarrhea) at six remote NT health centers from July to December 2015. The specific outcomes measured in this study were the number of unnecessary emergency medical retrieval prevented through POCT. Cost savings through prevented unnecessary medical retrievals for each presentation type were then determined and extrapolated to give per annum NT-wide estimates. POCT prevented 60 unnecessary medical evacuations from a total of 200 patient cases meeting the selection criteria (48/147 for chest pain, 10/28 for missed dialysis, and 2/25 for acute diarrhea). The associated cost savings were AUD $4,674, $8,034, and $786 per patient translating to NT-wide savings of AUD $13.72 million, $6.45 million, and $1.57 million per annum (AUD $21.75 million in total) for chest pain, missed dialysis, and acute diarrhea presentations, respectively. This study demonstrated that POCT when used to aid decision making for acutely ill patients delivered significant cost savings for the NT health care system by preventing unnecessary emergency medical retrievals.

Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes.

PubMed

Verghese, Abraham; Charlton, Blake; Kassirer, Jerome P; Ramsey, Meghan; Ioannidis, John P A

2015-12-01

Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting. Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half. Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination. Copyright © 2015 Elsevier Inc. All rights reserved.

Re: Madsen et al. "Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers".

PubMed

Durand-Moreau, Quentin; Loddé, Brice; Dewitte, Jean-Dominique

2015-03-01

Madsen et al (1) recently published a secondary analysis on data provided by the Project on Burnout, Motivation and Job Satisfaction (PUMA). The aim of their study, published in the Scandinavian Journal of Work, Environment & Health was to examine the associations between unnecessary work tasks and a decreased level of mental health. Though the topic was quite novel, reading this work proved disturbing and raised issues. Based on the results of this study, the authors stated that there is an association between unnecessary work tasks (assessed by a single question) and a decreased level of mental health, idem [assessed by the Mental Health Inventory (MHI-5)], in the specific population included in this PUMA survey. The authors point out a limitation of the study, namely that unnecessary work tasks were evaluated using one single question: "Do you sometimes have to do things in your job which appear to be unnecessary?". Semmer defines unnecessary work task as "tasks that should not be carried out at all because they do not make sense or because they could have been avoided, or could be carried out with less effort if things were organized more efficiently" (2). De facto, qualifying what an unnecessary task is requires stating or explaining whether the task makes sense. Making sense or not is not an objective notion. It is very difficult for either a manager or an employee to say if a task is necessary or not. Most important is that it makes sense from the worker's point of view. Making sense and being necessary are not synonyms. Some tasks do not make sense but are economically necessary (eg, when, as physicians, we are reporting our activity using ICD-10 on computers instead of being at patients' bedsides or reading this journal). Thus, there is a wide gap between Semmer's definition and the question used by the authors to evaluate his concept. A secondary analysis based on a single question is not adequate to evaluate unnecessary tasks. Nowadays, the general trend is to reduce the size of questionnaires because they are too long and cannot be used in a routine practice. But an analysis performed on a single question is quite risky: in psychometrics, redundancy is used to confirm a measurement. We lose precision on what exactly we are testing by asking a single question. Madsen et al's results show that among workers saying they are always or often performing unnecessary tasks, the MHI mean score was 74.00 versus 78.20 for people who never or almost never perform unnecessary tasks (P=0.0038). Even though it is a statistically significant result, its clinical relevance is never questioned. What is the impact of losing 4.20 points at MHI test instead of losing 20 points for instance? Statistical difference does not mean clinical relevance. These results show a statistical association, not a causality relationship. The authors did not show that performing unnecessary tasks lowers the level of mental health. It may be the exact opposite. Maybe having poorer mental health (eg, depression, with anhedonia) may make the workers think that what they're doing is useless. In their conclusion, Madsen et al suggest that the elimination of unnecessary work tasks may be beneficial for employees' mental health. To our mind, on the contrary, it may increase psychic suffering. If we suggest to fight unnecessary tasks in workplaces, this may encourage reduction of the margin of manoeuvre (3). The principle of removing unnecessary tasks is part of a Taylorized organization. Some tasks may seem unnecessary or bothersome, but may correspond to work periods that allow for temporary rest. Concretely, in the workplace, managers rather than the employee will be the ones to decide whether a task is useless or not. To improve well-being in the workplace, a global vision of work organization is required. From our point of view, the conclusion drawn from this study should not be that we must eliminate unnecessary tasks, but that we should focus on what makes sense for the worker, with a global view on his work and - as usual - the aim of carrying out further studies on this subject. Conflicts of interest The authors declare no conflict of interest. References 1. Madsen IEH, Tripathi M, Borritz M, Rugulies R, Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers, Scand J Work Environ Health. 2014;40(6):631-8. http://dx.doi.org/10.5271/sjweh.3453.  2. Semmer NK, Tschan F, Meier LL, Facchin S, Jacobshagen N, Illegitimate tasks and counterproductive work behavior, Appl Psychol. 2010;59:70-96. http://dx.doi.org/10.1111/j.1464-0597.2009.00416.x.  3. Durand MJ, Vézina N, Baril R, Loisel P, Richard MC, Ngomo S, Margin of manoeuvre indicators in the workplace during the rehabilitation process: a qualitative analysis, J Occup Rehab. 2009;19:194-202. http://dx.doi.org/10.1007/s10926-009-9173-4.

Lumbar spinal stenosis CAD from clinical MRM and MRI based on inter- and intra-context features with a two-level classifier

NASA Astrophysics Data System (ADS)

Koh, Jaehan; Alomari, Raja S.; Chaudhary, Vipin; Dhillon, Gurmeet

2011-03-01

An imaging test has an important role in the diagnosis of lumbar abnormalities since it allows to examine the internal structure of soft tissues and bony elements without the need of an unnecessary surgery and recovery time. For the past decade, among various imaging modalities, magnetic resonance imaging (MRI) has taken the significant part of the clinical evaluation of the lumbar spine. This is mainly due to technological advancements that lead to the improvement of imaging devices in spatial resolution, contrast resolution, and multi-planar capabilities. In addition, noninvasive nature of MRI makes it easy to diagnose many common causes of low back pain such as disc herniation, spinal stenosis, and degenerative disc diseases. In this paper, we propose a method to diagnose lumbar spinal stenosis (LSS), a narrowing of the spinal canal, from magnetic resonance myelography (MRM) images. Our method segments the thecal sac in the preprocessing stage, generates the features based on inter- and intra-context information, and diagnoses lumbar disc stenosis. Experiments with 55 subjects show that our method achieves 91.3% diagnostic accuracy. In the future, we plan to test our method on more subjects.

Clinical practice guideline: Bell's Palsy executive summary.

PubMed

Baugh, Reginald F; Basura, Gregory J; Ishii, Lisa E; Schwartz, Seth R; Drumheller, Caitlin Murray; Burkholder, Rebecca; Deckard, Nathan A; Dawson, Cindy; Driscoll, Colin; Gillespie, M Boyd; Gurgel, Richard K; Halperin, John; Khalid, Ayesha N; Kumar, Kaparaboyna Ashok; Micco, Alan; Munsell, Debra; Rosenbaum, Steven; Vaughan, William

2013-11-01

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Sputum color: potential implications for clinical practice.

PubMed

Johnson, Allen L; Hampson, David F; Hampson, Neil B

2008-04-01

Respiratory infections with sputum production are a major reason for physician visits, diagnostic testing, and antibiotic prescription in the United States. We sought to determine whether the simple characteristic of sputum color provides information that impacts resource utilization such as laboratory testing and prescription of antibiotics. Out-patient sputum samples submitted to the microbiology laboratory for routine analysis were assigned to one of 8 color categories (green, yellow-green, rust, yellow, red, cream, white, and clear), based on a key made from paint chip color samples. Subsequent Gram stain and culture results were compared to sputum color. Of 289 consecutive samples, 144 (50%) met standard Gram-stain criteria for being acceptable lower-respiratory-tract specimens. In the acceptable Gram-stain group, 60 samples had a predominant organism on Gram stain, and the culture yielded a consistent result in 42 samples (15% of the 289 total specimens). Yield at each level of analysis differed greatly by color. The yield from sputum colors green, yellow-green, yellow, and rust was much higher than the yield from cream, white, or clear. If out-patient sputum is cream, white, or clear, the yield from bacteriologic analysis is extremely low. This information can reduce laboratory processing costs and help minimize unnecessary antibiotic prescription.

Dealing with low-incidence serious diseases in general practice

PubMed Central

Buntinx, Frank; Mant, David; Van den Bruel, Ann; Donner-Banzhof, Norbert; Dinant, Geert-Jan

2011-01-01

Cost-effective health care depends on high-quality triage. The most challenging aspect of triage, which GPs confront on a regular basis, is diagnosing rare but serious disease. Failure to shoulder any risk in this situation overloads the health system and subjects patients to unnecessary investigation. Adopting too high a risk threshold leads to missed cases, late diagnosis, and sometimes avoidable death. It also undermines the credibility of primary care practitioners. Quantification of diagnostic risk suggests there is a potential risk gap between the maximum certainty with which GPs can assess the risk of serious disease at presentation and the minimum certainty required by many health systems for further investigation or hospital referral. Physician gut-feeling and diagnostic safety netting are often employed to fill the gap. Neither strategy is well defined or well supported by evidence. It should be possible to reduce the diagnostic risk gap cost-effectively by adopting more explicit diagnostic algorithms and providing better GP access to new diagnostic technologies. It is also essential, given the decreasing experience of triage clinicians employed in a number of countries, that a teachable evidence base is constructed for gut feeling and diagnostic safety netting. However, this construction of an evidence base requires very large-scale studies, and the global primary care research community remains small. The challenge therefore needs to be met by urgent and effective international collaboration. PMID:21401991

Cost-effectiveness of quantitative pretest probability intended to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.

PubMed

Troyer, Jennifer L; Jones, Alan E; Shapiro, Nathan I; Mitchell, Alice M; Hewer, Ian; Kline, Jeffrey A

2015-05-01

Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE. This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups. Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes. Widespread use of a combined qPTP for both ACS and PE has the potential to decrease costs by reducing diagnostic testing, while improving most long-term outcomes in emergency patients with chest pain and dyspnea. © 2015 by the Society for Academic Emergency Medicine.

Viral meningitis: current issues in diagnosis and treatment.

PubMed

McGill, Fiona; Griffiths, Michael J; Solomon, Tom

2017-04-01

The purpose of this review is to give an overview of viral meningitis and then focus in on some of the areas of uncertainty in diagnostics, treatment and outcome. Bacterial meningitis has been declining in incidence over recent years. Over a similar time period molecular diagnostics have increasingly been used. Because of both of these developments viral meningitis is becoming relatively more important. However, there are still many unanswered questions. Despite improvements in diagnostics many laboratories do not use molecular methods and even when they are used many cases still remain without a proven viral aetiology identified. There are also no established treatments for viral meningitis and the one potential treatment, aciclovir, which is effective in vitro for herpes simplex virus, has never been subjected to a clinical trial. Viruses are in increasingly important cause of meningitis in the era of declining bacterial disease. The exact viral aetiology varies according to age and country. Molecular diagnostics can not only improve the rate of pathogen detection but also reduce unnecessary antibiotics use and length of hospitalization. Further research is required into treatments for viral meningitis and the impact in terms of longer term sequelae.

Does NGAL reduce costs? A cost analysis of urine NGAL (uNGAL) & serum creatinine (sCr) for acute kidney injury (AKI) diagnosis

PubMed Central

Canetta, Pietro; Forster, Catherine; Sise, Meghan; Maarouf, Omar; Singer, Eugenia; Elger, Antje; Elitok, Saban; Schmidt-Ott, Kai; Barasch, Jonathon

2017-01-01

Introduction Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a sensitive and specific diagnostic test for acute kidney injury (AKI) in the Emergency Department (ED), but its economic impact has not been investigated. We hypothesized that uNGAL used in combination with serum creatinine (sCr) would reduce costs in the management of AKI in patients presenting to the ED in comparison to using sCr alone. Materials and methods A cost simulation model was developed for clinical algorithms to diagnose AKI based on sCr alone vs. uNGAL plus sCr (uNGAL+sCr). A cost minimization analysis was performed to determine total expected costs for patients with AKI. uNGAL test characteristics were validated with eight-hundred forty-nine patients with sCr ≥1.5 from a completed study of 1635 patients recruited from EDs at two U.S. hospitals from 2007–8. Biomarker test, AKI work-up, and diagnostic imaging costs were incorporated. Results For a hypothetical cohort of 10,000 patients, the model predicted that the expected costs were $900 per patient (pp) in the sCr arm and $950 in the uNGAL+sCr arm. uNGAL+sCr resulted in 1,578 fewer patients with delayed diagnosis and treatment than sCr alone (2,013 vs. 436 pts) at center 1 and 1,973 fewer patients with delayed diagnosis and treatment than sCr alone at center 2 (2,227 vs. 254 patients). Although initial evaluation costs at each center were $50 pp higher in with uNGAL+sCr, total costs declined by $408 pp at Center 1 and by $522 pp at Center 2 due to expected reduced delays in diagnosis and treatment. Sensitivity analyses confirmed savings with uNGAL + sCr for a range of cost inputs. Discussion Using uNGAL with sCr as a clinical diagnostic test for AKI may improve patient management and reduce expected costs. Any cost savings would likely result from avoiding delays in diagnosis and treatment and from avoidance of unnecessary testing in patients given a false positive AKI diagnosis by use of sCr alone. PMID:28542336

75 FR 38645 - Standards Improvement Project-Phase III

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-02

... are specified as ``ID,'' followed by the number of the document. OSHA posts these referenced materials... medical-testing requirement and eliminating an unnecessary and obsolete medical test required in both the... Sec. 1915.1001(h)(4)(ii) requires employers to perform quantitative and qualitative fit testing ``at...

Cytological Sampling Versus Forceps Biopsy During Percutaneous Transhepatic Biliary Drainage and Analysis of Factors Predicting Success

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tapping, C. R.; Byass, O. R.; Cast, J. E. I., E-mail: james.cast@hey.nhs.uk

Purpose: To assess the accuracy of cytological sampling and forceps biopsy in obstructing biliary lesions and to identify factors predictive of success. Methods: Consecutive patients (n = 119) with suspected malignant inoperable obstructive jaundice treated with percutaneous transhepatic biliary drainage during 7 years were included (60 male; mean age 72.5 years). All patients underwent forceps biopsy plus cytological sampling by washing the forceps device in cytological solution. Patient history, procedural and pathological records, and clinical follow-up were reviewed. Statistical analysis included chi-square test and multivariate regression analysis. Results: Histological diagnosis after forceps biopsy was more successful than cytology: Sensitivity wasmore » 78 versus 61%, and negative predictive value was 30 versus 19%. Cytology results were never positive when the forceps biopsy was negative. The cytological sample was negative and forceps sample positive in 2 cases of cholangiocarcinoma, 16 cases of pancreatic carcinoma, and 1 case of benign disease. Diagnostic accuracy was predicted by low bilirubin (p < 0.001), aspartate transaminase (p < 0.05), and white cell count (p {<=} 0.05). Conclusions: This technique is safe and effective and is recommended for histological diagnosis during PTBD in patients with inoperable malignant biliary strictures. Diagnostic yield is greater when bilirubin levels are low and there is no sepsis; histological diagnosis by way of forceps biopsy renders cytological sampling unnecessary.« less

Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction.

PubMed

Rohrich, Rod J; Ha, Richard Y; Kenkel, Jeffrey M; Adams, William P

2003-02-01

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.

Diagnostic challenges in clinical, radiological and histopathological tests regarding papillomatous lesions of the breast.

PubMed

Rasmussen, Birgitte Bruun; Balslev, Eva; Jarle Christensen, Ib; Lanng, Charlotte; Bak, Anne; Galatius, Hanne; Møller Talman, Maj-Lis; Sharghi Someh, Nahid; Vejborg, Ilse; Okholm, Mette

2018-05-22

Papillomas of the female breast is a relatively frequent lesion, and the majority are benign when excised. However, some may host malignant or premalignant areas. Consequently, it is a worldwide accepted principle to excise the lesion whenever diagnosed. However, this leads to a large number of patients having an unnecessary operation. The present study was designed to investigate whether we could find clinical, radiological and pathological factors in the preoperative, diagnostic setting that could identify patients hosting a benign papilloma in order to avoid operation. The patient material consisted of 260 patients, all with a preoperative diagnosis of a papillomatous process in core biopsy. The lesion was excised, and 71% had a benign lesion. The rest had lesions ranging from premalignant to malignant. In the clinical, radiological and histopathological investigations conducted, we were not able to identify factors that statistically significant could predict whether the lesion was benign or malignant. However, our data showed a higher prevalence of malignant and premalignant lesions for older patient, larger lesions, and lesions found at a longer distance from the papilla. We conclude that, since almost 30% of the patients in our study ended up with a premalignant or malignant diagnosis, where no statistically significant preoperative factors could indicate a benign outcome, operation is warranted in all patients with a preoperative diagnosis of a papillomatous lesion. Copyright © 2018 Elsevier Ltd. All rights reserved.

The role of human papillomavirus in screening for cervical cancer.

PubMed

McFadden, S E; Schumann, L

2001-03-01

To review the options for effectively screening for cervical cancer, including human papilloma virus (HPV) identification, cytologic screening, colposcopy, or a combination approach. Current pathophysiology, diagnostic criteria, treatment approaches, and patient preparation and education related to cervical cancer screening and prevention are also included. Comprehensive review of current literature, including research and review articles. Because the Papanicolau (Pap) smear is a screening tool, not a diagnostic tool, further studies must be done to identify the actual nature of discovered abnormalities. Of particular concern is the classification of atypical squamous cells of undetermined significance (ASCUS), which may simply indicate inflammation, or may be the first indicator of serious pathology. Following ASCUS Pap smears with HPV screening will allow for a clarification of the best approach to treatment. A screening algorithm supported by a review of the literature is proposed. Cervical cancer is a preventable disease caused by certain forms of HPV. Current screening protocols are based on the use of the Pap smear; and in areas where this test is routine and available, morbidity and mortality rates have dropped dramatically. Many women throughout the world and in underserved regions of the U. S. do not have adequate access to routine screening with Pap smear technology. As long as women continue to die needlessly of cervical cancer, more comprehensive and accessible screening methods must be explored. (Cutting the unnecessary worldwide and in the U. S.).

Determining the pregnancy status of patients before diagnostic nuclear medicine procedures: the Australian experience.

PubMed

James, Daphne J; Cardew, Paul; Warren-Forward, Helen M

2011-09-01

Ionizing radiation used in diagnostic nuclear medicine procedures has the potential to have biologic effects on a fetus. Nuclear medicine technologists (NMTs) therefore have a responsibility to ensure that they question all patients of childbearing age about their pregnancy status before starting any procedure, to avoid unnecessary fetal irradiation. In Australia, there are no clearly defined practice guidelines to assist NMTs in determining whom to question or how to question their patients. Semistructured interviews were conducted with chief NMTs and staff NMTs in 8 nuclear medicine departments in Australia. Questions were based around 5 areas: regulations and policy, fetal radiation exposure, questioning of the patient, difficulties in determining pregnancy status, and the impact of the use of hybrid imaging. Audio files of the interviews were transcribed and coded. Topics were coded into 5 themes: policy and awareness of guidelines, questioning the patient, radiation knowledge, decisions and assumptions made by NMTs, and the use of pregnancy testing. There was a wide variation in practice between and within departments. NMTs demonstrated a lack of knowledge and awareness of the possible biologic effects of radiation. This study identified a need in Australia for nuclear medicine to arrive at a consensus approach to verifying a patient's pregnancy status so that NMTs can successfully question patients about their pregnancy status. Continuing education programs are also required to keep NMTs up to date in their knowledge.

[A mistake in forensic psychiatric evaluation or abuse of psychiatry for non-medical purposes - a case report].

PubMed

Florkowski, Antoni; Zboralski, Krzysztof; Macander, Marian; Flinik-Jankowska, Magdalena; Wierzbiński, Piotr

2015-11-01

In this study we attempted to visualize certain irregularities that took place in the evaluation of a patient with personality disorders performed by psychiatrist expert witness, which resulted in an incorrect diagnosis, leading to wrong ruling of the court and a referral of the patient to clinical therapy lasting six years. The psychiatric and psychological expert opinions submitted to the court and first-hand psychiatric and psychological examination of the patient were analyzed. Efforts were made to show that the failure to comply with the diagnostic criteria in the process of diagnosis and not taking into account the previously issued five forensic psychiatric opinions issued by independent and experienced teams of psychiatrist expert witnesses, as well as not taking into account the nature of the offense committed have led to a number of irregularities in the assessment of the mental state of the patient. Above mentioned shortcomings have caused unjustified legal classification of the offense and six years long detention of the patient in closed psychiatric institutions, in our regard unnecessary. The described case could be regarded as an abuse of psychiatry for the non-medical purposes and thus should have be punish. Based on the presented case it has been demonstrated that insufficient experience in forensic psychiatry and failure to comply with diagnostic criteria of psychiatrists and psychologists expert witnesses had led to a series of blatant offense of civil rights and liberties, and thus unnecessary detention of the patient for six years. © 2015 MEDPRESS.

Sensitive Troponin I and Stress Testing in the Emergency Department for the Early Management of Chest Pain Using 2-Hour Protocol.

PubMed

Dadkhah, Shahriar; Almuwaqqat, Zakaria; Sulaiman, Samian; Husein, Husein; Nguyen, Quang; Ali, Saad; Taskesen, Tuncay

2017-09-01

Despite improvements in identifying high-risk patients with non-ST segment ACS (acute coronary syndrome), low risk patients presenting with atypical chest pain and non-diagnostic Electrocardiogram (ECG) continued to undergo unnecessary admissions and testing. Since 1992, our chest pain protocol included using 4-hour serial biomarkers from ED admission in combination with stress testing to evaluate these patients. Our study aimed at determining whether a new accelerated diagnostic protocol using sensitive cardiac troponin I (cTnI) 2 hours after admission to the ED followed by stress testing is safe and effective in emergency settings, allowing for appropriate triage, earlier discharge and reducing costs. We conducted a single center randomized trial at Presence St. Francis Hospital Chest pain center in Evanston, Illinois enrolling sixty-four consecutive patients with atypical chest pain and non-diagnostic ECG, participants were randomized to accelerated 2 hrs protocol or our pre-existing 4-hrs protocol. Sixty patients completed the protocol and were randomized to either a 2-hour (29 patients) or 4-hour protocol using both I-STAT and PATHFAST cTnI (31 Patients). Troponin I was evaluated at 0 and at 2 hours from ED presentation with and additional draw for patients in the 4-hour rule out-group. Patients with normal serial biomarkers were then evaluated with stress testing and qualified for earlier discharge if the stress test was negative, while those with a positive biomarker at any time were admitted. Thirty-six patients had exercise treadmill stress test and 24 patients had either nuclear or Echo stress test. Fifty-three patients had a normal stress test and were discharged home. One patient in the 4-hour group with normal serial troponins developed ventricular tachycardia/fibrillation during the recovery period of a regular stress test. Six patients had a positive PATHFAST cTnI and a normal I-STAT cTnI at 2-hours. Two out of these six patients evaluated by coronary angiography. One patient had severe tortuous coronaries but no significant obstructive lesion and one had a severe CAD who needed Coronary artery bypass grafting (CABG). Three of the six patients had a normal stress test and one patient decided to leave without further testing. None of the patients with a normal stress test had a major cardiac event or adverse cardiac outcome at six-month follow up. This study demonstrates that the 2 hours accelerated protocol using high sensitivity Troponin assay at 0 and 2 hours with comprehensive clinical evaluation and ECG followed by stress testing might be successful in identifying low-risk patient population who may benefit from early discharge from ED reducing associated costs and length of stay.

Development of a clinical decision model for thyroid nodules.

PubMed

Stojadinovic, Alexander; Peoples, George E; Libutti, Steven K; Henry, Leonard R; Eberhardt, John; Howard, Robin S; Gur, David; Elster, Eric A; Nissan, Aviram

2009-08-10

Thyroid nodules represent a common problem brought to medical attention. Four to seven percent of the United States adult population (10-18 million people) has a palpable thyroid nodule, however the majority (>95%) of thyroid nodules are benign. While, fine needle aspiration remains the most cost effective and accurate diagnostic tool for thyroid nodules in current practice, over 20% of patients undergoing FNA of a thyroid nodule have indeterminate cytology (follicular neoplasm) with associated malignancy risk prevalence of 20-30%. These patients require thyroid lobectomy/isthmusectomy purely for the purpose of attaining a definitive diagnosis. Given that the majority (70-80%) of these patients have benign surgical pathology, thyroidectomy in these patients is conducted principally with diagnostic intent. Clinical models predictive of malignancy risk are needed to support treatment decisions in patients with thyroid nodules in order to reduce morbidity associated with unnecessary diagnostic surgery. Data were analyzed from a completed prospective cohort trial conducted over a 4-year period involving 216 patients with thyroid nodules undergoing ultrasound (US), electrical impedance scanning (EIS) and fine needle aspiration cytology (FNA) prior to thyroidectomy. A Bayesian model was designed to predict malignancy in thyroid nodules based on multivariate dependence relationships between independent covariates. Ten-fold cross-validation was performed to estimate classifier error wherein the data set was randomized into ten separate and unique train and test sets consisting of a training set (90% of records) and a test set (10% of records). A receiver-operating-characteristics (ROC) curve of these predictions and area under the curve (AUC) were calculated to determine model robustness for predicting malignancy in thyroid nodules. Thyroid nodule size, FNA cytology, US and EIS characteristics were highly predictive of malignancy. Cross validation of the model created with Bayesian Network Analysis effectively predicted malignancy [AUC = 0.88 (95%CI: 0.82-0.94)] in thyroid nodules. The positive and negative predictive values of the model are 83% (95%CI: 76%-91%) and 79% (95%CI: 72%-86%), respectively. An integrated predictive decision model using Bayesian inference incorporating readily obtainable thyroid nodule measures is clinically relevant, as it effectively predicts malignancy in thyroid nodules. This model warrants further validation testing in prospective clinical trials.

Prostate-specific antigen testing in inner London general practices: are those at higher risk most likely to get tested?

PubMed

Nderitu, Paul; Van Hemelrijck, Mieke; Ashworth, Mark; Mathur, Rohini; Hull, Sally; Dudek, Alexandra; Chowdhury, Simon

2016-07-12

To investigate the association between factors influencing prostate-specific antigen (PSA) testing prevalence including prostate cancer risk factors (age, ethnicity, obesity) and non-risk factors (social deprivation and comorbidity). A cross-sectional database of 136 inner London general practices from 1 August 2009 to 31 July 2014. Men aged ≥40 years without prostate cancer were included (n=150 481). Logistic regression analyses were used to estimate the association between PSA testing and age, ethnicity, social deprivation, body mass index (BMI) and comorbidity while adjusting for age, benign prostatic hypertrophy, prostatitis and tamsulosin or finasteride use. PSA testing prevalence was 8.2% (2013-2014), and the mean age was 54 years (SD 11). PSA testing was positively associated with age (OR 70-74 years compared to 40-44 years: 7.34 (95% CI 6.82 to 7.90)), ethnicity (black) (OR compared to white: 1.78 (95% CI 1.71 to 1.85)), increasing BMI and cardiovascular comorbidity. Testing was negatively associated with Chinese ethnicity and with increasing social deprivation. PSA testing among black patients was higher compared to that among white patients, which differs from lower testing rates seen in previous studies. PSA testing was positively associated with prostate cancer risk factors and non-risk factors. Association with non-risk factors may increase the risk of unnecessary invasive diagnostic procedures. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Clinical Evaluation of an Affordable Qualitative Viral Failure Assay for HIV Using Dried Blood Spots in Uganda.

PubMed

Balinda, Sheila N; Ondoa, Pascale; Obuku, Ekwaro A; Kliphuis, Aletta; Egau, Isaac; Bronze, Michelle; Kasambula, Lordwin; Schuurman, Rob; Spieker, Nicole; Rinke de Wit, Tobias F; Kityo, Cissy

2016-01-01

WHO recommends regular viral load (VL) monitoring of patients on antiretroviral therapy (ART) for timely detection of virological failure, prevention of acquired HIV drug resistance (HIVDR) and avoiding unnecessary switching to second-line ART. However, the cost and complexity of routine VL testing remains prohibitive in most resource limited settings (RLS). We evaluated a simple, low-cost, qualitative viral-failure assay (VFA) on dried blood spots (DBS) in three clinical settings in Uganda. We conducted a cross-sectional diagnostic accuracy study in three HIV/AIDS treatment centres at the Joint Clinical Research Centre in Uganda. The VFA employs semi-quantitative detection of HIV-1 RNA amplified from the LTR gene. We used paired dry blood spot (DBS) and plasma with the COBASAmpliPrep/COBASTaqMan, Roche version 2 (VLref) as the reference assay. We used the VFA at two thresholds of viral load, (>5,000 or >1,000 copies/ml). 496 paired VFA and VLref results were available for comparative analysis. Overall, VFA demonstrated 78.4% sensitivity, (95% CI: 69.7%-87.1%), 93% specificity (95% CI: 89.7%-96.4%), 89.3% accuracy (95% CI: 85%-92%) and an agreement kappa = 0.72 as compared to the VLref. The predictive values of positivity and negativity among patients on ART for >12 months were 72.7% and 99.3%, respectively. VFA allowed 89% of correct classification of VF. Only 11% of the patients were misclassified with the potential of unnecessary or late switch to second-line ART. Our findings present an opportunity to roll out simple and affordable VL monitoring for HIV-1 treatment in RLS.

Clinical utility of an epigenetic assay to detect occult prostate cancer in histopathologically negative biopsies: results of the MATLOC study.

PubMed

Stewart, Grant D; Van Neste, Leander; Delvenne, Philippe; Delrée, Paul; Delga, Agnès; McNeill, S Alan; O'Donnell, Marie; Clark, James; Van Criekinge, Wim; Bigley, Joseph; Harrison, David J

2013-03-01

Concern about possible false-negative prostate biopsy histopathology findings often leads to rebiopsy. A quantitative methylation specific polymerase chain reaction assay panel, including GSTP1, APC and RASSF1, could increase the sensitivity of detecting cancer over that of pathological review alone, leading to a high negative predictive value and a decrease in unnecessary repeat biopsies. The MATLOC study blindly tested archived prostate biopsy needle core tissue samples of 498 subjects from the United Kingdom and Belgium with histopathologically negative prostate biopsies, followed by positive (cases) or negative (controls) repeat biopsy within 30 months. Clinical performance of the epigenetic marker panel, emphasizing negative predictive value, was assessed and cross-validated. Multivariate logistic regression was used to evaluate all risk factors. The epigenetic assay performed on the first negative biopsies of this retrospective review cohort resulted in a negative predictive value of 90% (95% CI 87-93). In a multivariate model correcting for patient age, prostate specific antigen, digital rectal examination and first biopsy histopathological characteristics the epigenetic assay was a significant independent predictor of patient outcome (OR 3.17, 95% CI 1.81-5.53). A multiplex quantitative methylation specific polymerase chain reaction assay determining the methylation status of GSTP1, APC and RASSF1 was strongly associated with repeat biopsy outcome up to 30 months after initial negative biopsy in men with suspicion of prostate cancer. Adding this epigenetic assay could improve the prostate cancer diagnostic process and decrease unnecessary repeat biopsies. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A NEW CLINICAL PREDICTION CRITERION ACCURATELY DETERMINES A SUBSET OF PATIENTS WITH BILATERAL PRIMARY ALDOSTERONISM BEFORE ADRENAL VENOUS SAMPLING.

PubMed

Kocjan, Tomaz; Janez, Andrej; Stankovic, Milenko; Vidmar, Gaj; Jensterle, Mojca

2016-05-01

Adrenal venous sampling (AVS) is the only available method to distinguish bilateral from unilateral primary aldosteronism (PA). AVS has several drawbacks, so it is reasonable to avoid this procedure when the results would not affect clinical management. Our objective was to identify a clinical criterion that can reliably predict nonlateralized AVS as a surrogate for bilateral PA that is not treated surgically. A retrospective diagnostic cross-sectional study conducted at Slovenian national endocrine referral center included 69 consecutive patients (mean age 56 ± 8 years, 21 females) with PA who underwent AVS. PA was confirmed with the saline infusion test (SIT). AVS was performed sequentially during continuous adrenocorticotrophic hormone (ACTH) infusion. The main outcome measures were variables associated with nonlateralized AVS to derive a clinical prediction rule. Sixty-seven (97%) patients had a successful AVS and were included in the statistical analysis. A total of 39 (58%) patients had nonlateralized AVS. The combined criterion of serum potassium ≥3.5 mmol/L, post-SIT aldosterone <18 ng/dL, and either no or bilateral tumor found on computed tomography (CT) imaging had perfect estimated specificity (and thus 100% positive predictive value) for bilateral PA, saving an estimated 16% of the patients (11/67) from unnecessary AVS. The best overall classification accuracy (50/67 = 75%) was achieved using the post-SIT aldosterone level <18 ng/dL alone, which yielded 74% sensitivity and 75% specificity for predicting nonlateralized AVS. Our clinical prediction criterion appears to accurately determine a subset of patients with bilateral PA who could avoid unnecessary AVS and immediately commence with medical treatment.

Author response to letter. Ref: Madsen et al. "Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers".

PubMed

Madsen, Ida Eh; Rugulies, Reiner

2015-03-01

We read with interest the letter from Drs Durand-Moreau, Loddé, and Dewitte (1) regarding our article on unnecessary work tasks and mental health (2). The authors argue that: (i) the article is flawed by an imprecise one-item exposure measurement, (ii) the results may be affected by reverse causality, and (iii) ultimately the elimination of unnecessary work tasks may increase "psychic suffering". We would like to take this opportunity to address their concerns. We acknowledge, as we did in the article itself, that measuring unnecessary work tasks using only one item is less than ideal and could have increased measurement error in our analyses. The item we used to measure unnecessary work tasks assesses the employee's overall evaluation regarding the extent to which they must conduct work tasks that they, for whatever reason, deem unnecessary. We are unconvinced by the claim by Drs Durand-Moreau, Loddé, and Dewitte that this phenomenon is somehow unrelated to Semmer's definition of unnecessary tasks (3, 4), regardless of the sense-making processes underlying an individual employee's evaluation of a particular work task as unnecessary. Regarding the issue of reverse causality, the analyses were longitudinal and the effect estimates were adjusted for the baseline mental health level of the participants. Consequently, we examined changes in mental health over time, and our results cannot be explained by poorer mental health making workers think "that what they're doing is useless" as claimed in the commentary. Although causal inference is always a delicate issue when applying observational research methods, the adjustment for baseline mental health should account for reverse causality at least. Drs Durand-Moreau, Loddé, and Dewitte question that our findings suggest that the elimination of unnecessary work tasks may be beneficial to employee mental health. Instead they propose that unnecessary work tasks may be conducive to mental health because "some tasks may seem unnecessary or bothersome, but may correspond to work periods that allow for temporary rest". We find this suggestion curious and are not aware of any empirical studies to support this claim. Consequently, we encourage the authors of the commentary to test their hypothesis empirically. Any such empirical evidence would be a welcome advancement to the scientific knowledge concerning the mental health consequences of unnecessary work tasks. As the results of our study do not indicate that unnecessary work tasks could be beneficial to mental health, but indeed that they could be harmful, we find no reason to modify the conclusions of our article. References 1. Durand-Moreau Q, Loddé B, Dewitte J-D. Ref: Madsen et al. "Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers". Scand J Work Environ Health - online first. http://dx.doi.org/10.5271/sjweh.3473. 2. Madsen IEH, Tripathi M, Borritz M, Rugulies R, Unnecessary work tasks and mental health: a prospective analysis of Danish human service workers, Scand J Work Environ Health. 2014;40(6):631-8. http://dx.doi.org/10.5271/sjweh.3453.  3. Semmer NK, Tschan F, Meier LL, Facchin S, Jacobshagen N, Illegitimate tasks and counterproductive work behavior, Appl Psychol. 2010;59:70-96. http://dx.doi.org/10.1111/j.1464-0597.2009.00416.x.  4. Durand MJ, Vézina N, Baril R, Loisel P, Richard MC, Ngomo S, Margin of manoeuvre indicators in the workplace during the rehabilitation process: a qualitative analysis, J Occup Rehab. 2009;19:194-202. http://dx.doi.org/10.1007/s10926-009-9173-4.

Chest pain emergency centers: improving acute myocardial infarction care.

PubMed

Ornato, J P

1999-08-01

Uncertainty and delay are common in the diagnosis of acute coronary syndromes (ACS). In the last 20 years, the need for faster, more accurate, and more cost-effective diagnosis gave rise to the concept of specialized treatment of patients with chest pain in emergency departments (EDs). The original strategy dedicated a separate section of the ED and a nursing staff to the task of rapid intervention in patients with acute myocardial infarction (MI) and triage of low-risk patients. Chest pain centers grew quickly in popularity but evolved with a variety of goals, staffing plans, diagnostic resources, and levels of commitment. There existing centers--the University of Cincinnati Heart ER, Brigham and Women's Hospital, and the Medical College of Virginia--have implemented chest pain strategies with the common aims of (1) screening for the entire spectrum of coronary artery disease, (2) avoiding unnecessary admissions, and (3) using multiple diagnostic modalities. Yet, they differ in the specifics of their approaches and diagnostic methods (e.g., echocardiography vs. treadmill vs. myocardial perfusion imaging). The safety and cost effectiveness of these centers are discussed.

Non-invasive spectroscopic techniques in the diagnosis of non-melanoma skin cancer

NASA Astrophysics Data System (ADS)

Drakaki, E.; Sianoudis, IA; Zois, EN; Makropoulou, M.; Serafetinides, AA; Dessinioti, C.; Stefanaki, E.; Stratigos, AJ; Antoniou, C.; Katsambas, A.; Christofidou, E.

2017-11-01

The number of non-melanoma skin cancers is increasing worldwide and has become an important health and economic issue. Early detection and treatment of skin cancer can significantly improve patient outcome. Therefore there is an increase in the demand for proper management and effective non-invasive diagnostic modalities in order to avoid relapses or unnecessary treatments. Although the gold standard of diagnosis for non-melanoma skin cancers is biopsy followed by histopathology evaluation, optical non-invasive diagnostic tools have obtained increased attention. Emerging non-invasive or minimal invasive techniques with possible application in the diagnosis of non-melanoma skin cancers include high-definition optical coherence tomography, fluorescence spectroscopy, oblique incidence diffuse reflectance spectrometry among others spectroscopic techniques. Our findings establish how those spectrometric techniques can be used to more rapidly and easily diagnose skin cancer in an accurate and automated manner in the clinic.

Electronic decision support for diagnostic imaging in a primary care setting

PubMed Central

Reed, Martin H

2011-01-01

Methods Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines. Results Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software. Conclusions Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow. PMID:21486884

Solitary Fibrous Tumor of Retromolar Pad; a Rare Challenging Case

PubMed Central

Lotfi, Ali; Mokhtari, Sepideh; Moshref, Mohammad; Shahla, Maryam; Atarbashi Moghadam, Saede

2017-01-01

Solitary fibrous tumor has a wide spectrum of histopathologic features and many tumors show similar microscopic features. This similarity poses diagnostic challenges to the pathologists and immunohistochemical analysis is required in many cases. Moreover, it is a rare entity in orofacial region which consequently would make its diagnosis more challenging in oral cavity. The knowledge of various microscopic patterns of this tumor contributes to a proper diagnosis and prevents unnecessary treatment. This study reports a case of solitary fibrous tumor in the retromolar pad area and discusses its various histological features and differential diagnoses. PMID:28620640

Rib fracture following stereotactic body radiotherapy: a potential pitfall.

PubMed

Stanic, Sinisa; Boike, Thomas P; Rule, William G; Timmerman, Robert D

2011-11-01

Although the incidence of rib fractures after conventional radiotherapy is generally low (<2%), rib fractures are a relatively common complication of stereotactic body radiotherapy. For malignancy adjacent to the chest wall, the incidence of rib fractures after stereotactic body radiotherapy is as high as 10%. Unrecognized bone fractures can mimic bone metastases on bone scintigraphy, can lead to extensive workup, and can even lead to consideration of unnecessary systemic chemotherapy, as treatment decisions can be based on imaging findings alone. Nuclear medicine physicians and diagnostic radiologists should always consider rib fracture in the differential diagnosis.

Bowel obsession syndrome in a patient with ulcerative colitis.

PubMed

Porcelli, Piero; Leandro, Gioacchino

2007-01-01

Gastroenterologists are often faced with the diagnostic problem of differentiating acute symptoms of ulcerative colitis from functional intestinal disorders. Bowel obsession syndrome (BOS) is an OCD-like, functional syndrome characterized by fear of fecal incontinence and compulsive behaviors of evacuation-checking. Only sparse case studies on treatment of BOS with antidepressants have been published. This is the first study on successful psychotherapy of a male patient with ulcerative colitis overlapping functional bowel symptoms and marked symptoms of BOS. Clinical recognition of BOS may help clinicians in differential diagnosis, prevent unnecessary investigations, and give patients the most appropriate treatment.

Radiology of pancreatic neoplasms: An update

PubMed Central

de la Santa, Luis Gijón; Retortillo, José Antonio Pérez; Miguel, Ainhoa Camarero; Klein, Lea Marie

2014-01-01

Diagnostic imaging is an important tool to evaluate pancreatic neoplasms. We describe the imaging features of pancreatic malignancies and their benign mimics. Accurate detection and staging are essential for ensuring appropriate selection of patients who will benefit from surgery and for preventing unnecessary surgeries in patients with unresectable disease. Ultrasound, multidetector computed tomography with multiplanar reconstruction and magnetic resonance imaging can help to do a correct diagnosis. Radiologists should be aware of the wide variety of anatomic variants and pathologic conditions that may mimic pancreatic neoplasms. The knowledge of the most important characteristic key findings may facilitate the right diagnosis. PMID:25232458

Radiology of pancreatic neoplasms: An update.

PubMed

de la Santa, Luis Gijón; Retortillo, José Antonio Pérez; Miguel, Ainhoa Camarero; Klein, Lea Marie

2014-09-15

Diagnostic imaging is an important tool to evaluate pancreatic neoplasms. We describe the imaging features of pancreatic malignancies and their benign mimics. Accurate detection and staging are essential for ensuring appropriate selection of patients who will benefit from surgery and for preventing unnecessary surgeries in patients with unresectable disease. Ultrasound, multidetector computed tomography with multiplanar reconstruction and magnetic resonance imaging can help to do a correct diagnosis. Radiologists should be aware of the wide variety of anatomic variants and pathologic conditions that may mimic pancreatic neoplasms. The knowledge of the most important characteristic key findings may facilitate the right diagnosis.

Biological Effects and Safety in Magnetic Resonance Imaging: A Review

PubMed Central

Hartwig, Valentina; Giovannetti, Giulio; Vanello, Nicola; Lombardi, Massimo; Landini, Luigi; Simi, Silvana

2009-01-01

Since the introduction of Magnetic Resonance Imaging (MRI) as a diagnostic technique, the number of people exposed to electromagnetic fields (EMF) has increased dramatically. In this review, based on the results of a pioneer study showing in vitro and in vivo genotoxic effects of MRI scans, we report an updated survey about the effects of non-ionizing EMF employed in MRI, relevant for patients’ and workers’ safety. While the whole data does not confirm a risk hypothesis, it suggests a need for further studies and prudent use in order to avoid unnecessary examinations, according to the precautionary principle. PMID:19578460

[Overdiagnosis in cancer screening].

PubMed

Cervera Deval, J; Sentís Crivillé, M; Zulueta, J J

2015-01-01

In screening programs, overdiagnosis is defined as the detection of a disease that would have gone undetected without screening when that disease would not have resulted in morbimortality and was treated unnecessarily. Overdiagnosis is a bias inherent in screening and an undesired effect of secondary prevention and improved sensitivity of diagnostic techniques. It is difficult to discriminate a priori between clinically relevant diagnoses and those in which treatment is unnecessary. To minimize the effects of overdiagnosis, screening should be done in patients at risk. Copyright © 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Awareness of allergic enterocolitis among primary-care paediatricians: A web-based pilot survey.

PubMed

Comberiati, P; Landi, M; Martelli, A; Piacentini, G L; Capristo, C; Paiola, G; Peroni, D G

2016-01-01

Allergic enterocolitis, also known as food protein-induced enterocolitis syndrome (FPIES), is an increasingly reported and potentially severe non-IgE mediated food allergy of the first years of life, which is often misdiagnosed due to its non-specific presenting symptoms and lack of diagnostic guidelines. We sought to determine the knowledge of clinical, diagnostic and therapeutic features of FPIES among Italian primary-care paediatricians. A 16-question anonymous web-based survey was sent via email to randomly selected primary care paediatricians working in the north of Italy. There were 194 completed surveys (48.5% response rate). Among respondents, 12.4% declared full understanding of FPIES, 49% limited knowledge, 31.4% had simply heard about FPIES and 7.2% had never heard about it. When presented with clinical anecdotes, 54.1% recognised acute FPIES and 12.9% recognised all chronic FPIES, whereas 10.3% misdiagnosed FPIES as allergic proctocolitis or infantile colic. To diagnose FPIES 55.7% declared to need negative skin prick test or specific-IgE to the trigger food, whereas 56.7% considered necessary a confirmatory oral challenge. Epinephrine was considered the mainstay in treating acute FPIES by 25.8% of respondents. Only 59.8% referred out to an allergist for the long-term reintroduction of the culprit food. Overall, 20.1% reported to care children with FPIES in their practice, with cow's milk formula and fish being the most common triggers; the diagnosis was self-made by the participant in 38.5% of these cases and by an allergist in 48.7%. There is a need for promoting awareness of FPIES to minimise delay in diagnosis and unnecessary diagnostic and therapeutic interventions. Copyright © 2016 SEICAP. Published by Elsevier España, S.L.U. All rights reserved.

Awareness and Knowledge of Ionizing Radiation Risks Between Prescribed and Self-Presenting Patients for Common Diagnostic Radiological Procedures in Bahrain

PubMed Central

Al-Mallah, Adel; Vaithinathan, Asokan G.; Al-Sehlawi, Mahdi; Al-Mannai, Mariam

2017-01-01

Objectives Between 20 to 50% of medical imaging examinations are considered inappropriate, and unnecessary ionizing radiation exposures may lead to cancer. We hypothesized that Bahraini patients who self-present for ionizing radiation procedures are not aware of, and lack the requisite knowledge of, the inherent risks associated with their use than patients prescribed for diagnostic purposes. We attempted to examine and compare the awareness and knowledge of the associated risks of ionizing radiation in common diagnostic radiological procedures between prescribed and self-presenting patients in Bahrain. Methods A cross-sectional survey was carried out among 416 Bahraini patients attending the radiology department of the Salmaniya Medical Complex (SMC), a secondary health care center, who had been referred by primary care physicians or self-presented to the center. Data was collected via face-to-face interviews. Results Prescribed patients (n = 358) had a better awareness than self-presenting (n = 58) patients on all ionizing radiation awareness statements (i.e., risks, permissible levels, willingness to undergo the procedure, and preference for a clinical examination over a radiological procedure) (p < 0.050). Of the 10 knowledge statements, the prescribed patients agreed on four statements than the self-presenting patients: preventing or minimizing exposure improves health, people can prevent or minimize exposure, a lifelong health concern, and radiological procedures offer best diagnoses compared to medical tests or procedures (p <  0.050). Conclusions Bahraini patients who reported to SMC lack awareness and knowledge on ionizing radiation. The proportion of appropriate responses to awareness and knowledge questions were paltry for self-presenting patients and deficient for the prescribed patients in the knowledge segment alone. PMID:29026468

A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies.

PubMed

Thornley, T; Marshall, G; Howard, P; Wilson, A P R

2016-11-01

The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15. Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment. Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available. This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.

Prospective multi-center study for quantification of chemotherapies and CTX-related direct medication costs avoided by use of biomarkers uPA and PAI-1 in primary breast cancer.

PubMed

Jacobs, Volker R; Augustin, Doris; Wischnik, Arthur; Kiechle, Marion; Höss, Cornelia; Steinkohl, Oliver; Rack, Brigitte; Kapitza, Thomas; Krase, Peter

2013-08-01

Biomarkers uPA/PAI-1 as recommended by ASCO and AGO are used in primary breast cancer to avoid unnecessary CTX in medium risk-recurrence patients. This study verified how many CTX cycles and CTX-related direct medication costs can be avoided by uPA/PAI-1 testing. A prospective, non-interventional, multi-center study was performed among six Certified Breast Centers to analyze application of uPA/PAI-1 and consecutive decision-making. CTX avoided were identified and direct costs for CTX, CTX-related concomitant medication and febrile neutropenia (FN) prophylaxis with G-CSF calculated. In n = 93 breast cancers n = 35 CTX (37.6%) with 210 CTX cycles were avoided according to uPA/PAI-1 test result. uPA/PAI-1 testing saved direct medication costs for CTX of 177,453 €, CTX-related concomitant medication of 27,482 € and FN prophylaxis of 20,599 €, overall 225,534 €. At test costs at 287.50 € uPA/PAI-1 testing resulted in additional costs of 26,737.50 €. uPA/PAI-1 has proven to be cost-effective at a return-on-investment ratio of 8.4:1. Indirect cost savings further increase this ROI. These results support decision-making for cost-effective diagnostics and therapy in breast cancer. Copyright © 2013 Elsevier Ltd. All rights reserved.

Another Setting for Stewardship: High Rate of Unnecessary Antimicrobial Use in a VA Long-Term Care Facility

PubMed Central

Peron, Emily P.; Hirsch, Amy A.; Jury, Lucy A.; Jump, Robin L.P.; Donskey, Curtis J.

2015-01-01

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria. PMID:23405923

An Audit of Repeat Testing at an Academic Medical Center: Consistency of Order Patterns With Recommendations and Potential Cost Savings.

PubMed

Hueth, Kyle D; Jackson, Brian R; Schmidt, Robert L

2018-05-31

To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression. Of the evaluated 4,242 repeated target tests, 1,849 (44%) were identified as PURT, representing an estimated cost-savings opportunity of $37,376. Collectively, the association of result positivity and PURT was statistically significant (relative risk, 1.2; 95% confidence interval, 1.1-1.3; P < .001). PURT contributes to unnecessary health care costs. We found that a small percentage of providers account for the majority of PURT, and PURT is positively associated with result positivity.

CT vs. MRCP in choledocholithiasis jaundice.

PubMed

Petrescu, I; Bratu, A M; Petrescu, S; Popa, B V; Cristian, D; Burcos, T

2015-01-01

Obstructive jaundice can raise problems to diagnostic imaging. The radiologist must choose the most appropriate examination that delivers the most important diagnostic information because the differences between a lithiasic obstruction and a tumoral one are vital. This information helps the surgeon speed up the process of decision-making, because the treatment may be very different in relation to the nature of the obstruction. This study tries to demonstrate the diagnostic accuracy of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) in detecting the obstacle in the common bile duct (CBD) and the possibility of establishing the lithiasic nature of the obstruction. A retrospective analysis was analyzed during an interval of 18 months that included jaundice patients admitted in the General Surgery Department of "Coltea" Clinical Hospital. They were examined by CT scanning and by MRCP, being suspected of choledocholithiasis. 63 patients were included in the study, 34 females and 29 males. 33 CT scans and 30 MRCP exams were performed. CT scan is useful in detecting residual or iterative choledocholithiasis in patients after cholecystectomy, contrast enhanced CT (CECT), being able to differentiate between lithiasic and non-lithiasic obstruction. MRCP delivers important anatomic details of the biliary tree; it is superior to CT in diagnosing the hepatocholedochal lithiasis; MRCP tends to replace endoscopic retrograde cholangiopancreatography (ERCP)--the diagnostic "gold standard" reducing the number of unnecessary invasive diagnostic procedures.

Strategies for Diagnosing and Treating Suspected Acute Bacterial Sinusitis

PubMed Central

Balk, Ethan M; Zucker, Deborah R; Engels, Eric A; Wong, John B; Williams, John W; Lau, Joseph

2001-01-01

OBJECTIVE Symptoms suggestive of acute bacterial sinusitis are common. Available diagnostic and treatment options generate substantial costs with uncertain benefits. We assessed the cost-effectiveness of alternative management strategies to identify the optimal approach. DESIGN For such patients, we created a Markov model to examine four strategies: 1) no antibiotic treatment; 2) empirical antibiotic treatment; 3) clinical criteria-guided treatment; and 4) radiography-guided treatment. The model simulated a 14-day course of illness, included sinusitis prevalence, antibiotic side effects, sinusitis complications, direct and indirect costs, and symptom severity. Strategies costing less than $50,000 per quality-adjusted life year gained were considered “cost-effective.” MEASUREMENTS AND MAIN RESULTS For mild or moderate disease, basing antibiotic treatment on clinical criteria was cost-effective in clinical settings where sinusitis prevalence is within the range of 15% to 93% or 3% to 63%, respectively. For severe disease, or to prevent sinusitis or antibiotic side effect symptoms, use of clinical criteria was cost-effective in settings with lower prevalence (below 51% or 44%, respectively); empirical antibiotics was cost-effective with higher prevalence. Sinus radiography-guided treatment was never cost-effective for initial treatment. CONCLUSIONS Use of a simple set of clinical criteria to guide treatment is a cost-effective strategy in most clinical settings. Empirical antibiotics are cost-effective in certain settings; however, their use results in many unnecessary prescriptions. If this resulted in increased antibiotic resistance, costs would substantially rise and efficacy would fall. Newer, expensive antibiotics are of limited value. Additional testing is not cost-effective. Further studies are needed to find an accurate, low-cost diagnostic test for acute bacterial sinusitis. PMID:11679039

Can corneal pannus with trachomatous inflammation--follicular be used in combination as an improved specific clinical sign for current ocular Chlamydia trachomatis infection?

PubMed

Derrick, Tamsyn; Holland, Martin J; Cassama, Eunice; Markham-David, Rod; Nabicassa, Meno; Marks, Michael; Bailey, Robin L; Last, Anna R

2016-01-27

Trachoma is a blinding disease caused by conjunctival infection with Chlamydia trachomatis (Ct). Mass drug administration (MDA) for trachoma control is administered based on the population prevalence of the clinical sign of trachomatis inflammation - follicular (TF). However, the prevalence of TF is often much higher than the prevalence of Ct infection. The addition of a clinical sign specific for current ocular Ct infection to TF could save resources by preventing unnecessary additional rounds of MDA. Study participants were aged between 1-9 years and resided on 7 islands of the Bijagos Archipelago, Guinea Bissau. Clinical grades for trachoma and corneal pannus and ocular swab samples were taken from 80 children with TF and from 81 matched controls without clinical evidence of trachoma. Ct infection testing was performed using droplet digital PCR. New pannus was significantly associated with Ct infection after adjustment for TF (P = 0.009, OR = 3.65 (1.4-9.8)). Amongst individuals with TF, individuals with new pannus had significantly more Ct infection than individuals with none or old pannus (75.0% vs 45.5%, Chi(2) P = 0.01). TF and new pannus together provide a highly specific (91.7%), but a poorly sensitive (51.9%) clinical diagnostic test for Ct infection. As we move towards trachoma elimination it may be desirable to use a combined clinical sign (new pannus in addition to TF) that is highly specific for current ocular Ct infection. This would allow national health systems to obtain a more accurate estimate of Ct population prevalence to inform further need for MDA without the expense of Ct molecular diagnostics, which are currently unaffordable in programmatic contexts.

Reducing Unnecessary and Duplicate Ordering for Ovum and Parasite Examinations and Clostridium difficile PCR in Immunocompromised Patients by Using an Alert at the Time of Request in the Order Management System

PubMed Central

Shuptar, Susan L.; Milord, Philippe; Essick, Connor J.; Nevrekar, Reshma; Granovsky, Svetlana L.; Seo, Susan K.; Martin, Steven C.; Pessin, Melissa S.

2015-01-01

We implemented hospital information system (HIS) alerts to deter unnecessary test orders for ovum and parasite (O&P) exams and Clostridium difficile PCR. The HIS alerts decreased noncompliant O&P orders (orders after >72 h of hospitalization) from 49.8% to 30.9%, an overall decrease of 19%, and reduced noncompliant C. difficile PCR orders (orders <7 days after a previous positive result) from 30.6% to 19.2%, an overall decrease of 31.9%. PMID:26063860

Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial.

PubMed

Verbakel, Jan Y; Lemiengre, Marieke B; De Burghgraeve, Tine; De Sutter, An; Aertgeerts, Bert; Shinkins, Bethany; Perera, Rafael; Mant, David; Van den Bruel, Ann; Buntinx, Frank

2016-10-06

Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment. Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12-30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L. Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8-82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6-45.6 %) had a CRP < 5 mg/L. CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals. ClinicalTrials.gov Identifier: NCT02024282 (registered on 14 th September 2012).

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study).

PubMed

Azuara-Blanco, Augusto; Banister, Katie; Boachie, Charles; McMeekin, Peter; Gray, Joanne; Burr, Jennifer; Bourne, Rupert; Garway-Heath, David; Batterbury, Mark; Hernández, Rodolfo; McPherson, Gladys; Ramsay, Craig; Cook, Jonathan

2016-01-01

Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population. To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma. Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care. Secondary care. Adults referred from the community to hospital eye services for possible glaucoma. Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement. (1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY). Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs. Automated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective. There are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored. The National Institute for Health Research Health Technology Assessment programme.

Lunar Surface Reference Missions: A Description of Human and Robotic Surface Activities

NASA Technical Reports Server (NTRS)

Duke, Michael B.; Hoffman, Stephen J.; Snook, Kelly

2003-01-01

Most medical equipment to the International Space Station (ISS) is manisfested as part of the U.S. or the Russian medical hardware systems. However, certain medical hardware is also available as part of the Human Research Facility. The HRF and the JSC Medical Operations Branch established a Memorandum of Agreement for joint use of certain medical hardware, including the HRF ultrasound system, the only diagnostic imaging device currently manifested to fly on ISS. The outcome of a medical contingency may be changed drastically, or an unnecessary evacuation may be prevented, if clinical decisions are supported by timely and objective diagnostic information. In many higher-probability medical scenarios, diagnostic ultrasound is a first-choice modality or provides significant diagnostic information. Accordingly, the Clinical Care Capability Development Project is evaluating the HRF ultrasound system for its utility in relevant clinical siruations on board ISS. For effective management of these ultrasound-supported ISS medical scenarios, the resulting data should be available for viewing and interpretation on the ground, and bidirectional voice communication should be readily available to allow ground experts (sonographers, physicians) to provide guidance to the Crew Medical Officer. It may also be vitally important to have the capability of real-time guidance via video uplink to the CMO-opertor during an exam to facilitate the diagnosis in a timely fashion.

Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study.

PubMed

Salemis, Nikolaos S; Gourgiotis, Stavros; Karalis, Georgios

2010-01-01

Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain. It may mimic a wide variety of intraabdominal disorders thus frequently leading to delay in treatment, increased morbidity or even in an unnecessary surgery. This is a retrospective study of 10 patients with RSH who were treated in our department over a five-year period. There were 6 (60%) men and 4 (40%) women ranging in age from 38 to 86 years, with a mean age of 57.1 years. The most common clinical presentation was a palpable abdominal mass associated with abdominal pain. Computed tomography (CT) established the diagnosis in 100% of the cases. 4 patients had type I hematoma, 3 had type II hematoma and 3 had type III hematoma. Anticoagulation therapy was the most common predisposing factor. Conservative treatment was effective in 90% of the cases and in all cases of spontaneous RSHs in patients under anticoagulation therapy. One patient, who developed a very severe RSH following an abdominal injection of low-molecular-weight heparin (LMWH), underwent surgery. All patients with type III hematoma required blood transfusion. RSH should be considered in the differential diagnosis of the elderly patients under anticoagulation therapy presenting with acute abdominal pain and a palpable mass. CT is the diagnostic modality of choice. Conservative treatment is feasible in most cases. Early diagnosis is mandatory in order to avoid morbidity or unnecessary surgery. In order to prevent a traumatic RSH, trocar insertion under direct vision during laparoscopic surgery and careful attention in the abdominal administration of LMWH are essential. Copyright (c) 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

PubMed

Schwartz, Alan; Weiner, Saul J; Weaver, Frances; Yudkowsky, Rachel; Sharma, Gunjan; Binns-Calvey, Amy; Preyss, Ben; Jordan, Neil

2012-11-01

In a past study using unannounced standardised patients (USPs), substantial rates of diagnostic and treatment errors were documented among internists. Because the authors know the correct disposition of these encounters and obtained the physicians' notes, they can identify necessary treatment that was not provided and unnecessary treatment. They can also discern which errors can be identified exclusively from a review of the medical records. To estimate the avoidable direct costs incurred by physicians making errors in our previous study. In the study, USPs visited 111 internal medicine attending physicians. They presented variants of four previously validated cases that jointly manipulate the presence or absence of contextual and biomedical factors that could lead to errors in management if overlooked. For example, in a patient with worsening asthma symptoms, a complicating biomedical factor was the presence of reflux disease and a complicating contextual factor was inability to afford the currently prescribed inhaler. Costs of missed or unnecessary services were computed using Medicare cost-based reimbursement data. Fourteen practice locations, including two academic clinics, two community-based primary care networks with multiple sites, a core safety net provider, and three Veteran Administration government facilities. Contribution of errors to costs of care. Overall, errors in care resulted in predicted costs of approximately $174,000 across 399 visits, of which only $8745 was discernible from a review of the medical records alone (without knowledge of the correct diagnoses). The median cost of error per visit with an incorrect care plan differed by case and by presentation variant within case. Chart reviews alone underestimate costs of care because they typically reflect appropriate treatment decisions conditional on (potentially erroneous) diagnoses. Important information about patient context is often entirely missing from medical records. Experimental methods, including the use of USPs, reveal the substantial costs of these errors.

A case of pachydermodactyly in a seventeen year old associated with repetitive minor trauma.

PubMed

Abdelrahman, W; Walsh, M Y; Smyth, A; Alderice, D

2016-08-15

A boy presented initially to a Rheumatology clinic with a three year history of asymptomatic swelling of the third to fourth proximal interphalangeal (PIP) joints bilaterally. A presumptive diagnosis of seronegative arthritis was made. Sulfasalazine was commenced without improvement and resulted in mood disturbance. Blood tests including ESR, lupus anticoagulant, rheumatoid factor and CCP antibodies were unremarkable. Hand radiographs were normal. MRI showed oedema within soft tissues around PIP joints. His care was transferred to the Rheumatology unit in our hospital and the rheumatological diagnosis was revised; sulfasalazine was stopped and skin biopsy organised. Onward referral to Dermatology was made. Examination revealed symmetrical swelling and thickening of soft tissues on PIP joints with no evidence of joint synovitis. He denied habitual behaviour but was noted to rub his fingers subconsciously. With this as a cause of repetitive minor trauma, a clinical diagnosis of pachydermodactyly was made. Skin biopsy was supportive showing a dermis with coarse collagen. Pachydermodactyly is rare. This case highlights the importance of prompt recognition to avoid invasive and excessive diagnostic procedures as well as unnecessary immunosuppression.

Benign skin disease with pustules in the newborn*

PubMed Central

Reginatto, Flávia Pereira; Villa, Damie De; Cestari, Tania Ferreira

2016-01-01

The neonatal period comprises the first four weeks of life. It is a period of adaptation where the skin often presents several changes: transient lesions, resulting from a physiological response, others as a consequence of transient diseases and some as markers of severe disorders. The presence of pustules in the skin of the newborn is always a reason for the family and for the assisting doctor to be worried, since the newborn is especially vulnerable to bacterial, viral or fungal infection. However, the majority of neonatal skin pustules is not infectious, comprising the benign neonatal pustulosis. Benign neonatal pustuloses are a group of clinical disease characterized by pustular eruptions in which a contagious agent is not responsible for its etiology. The most common ones are erythema toxicum neonatorum, the transient neonatal pustular melanosis and the benign cephalic pustulosis. These dermatoses are usually benign, asymptomatic and self-limited. It is important that the dermatologist and the neonatologist can identify benign and transient lesions, those caused by genodermatoses, and especially differentiate between neonates with systemic involvement from those with benign skin lesions, avoiding unnecessary diagnostic tests and worries. PMID:27192509

NEEDLE BIOPSY OF THE LIVER—General Considerations

PubMed Central

Molle, William E.; Kaplan, Leo

1952-01-01

Needle biopsy of the liver provides concrete diagnostic information that cannot be as readily obtained in any other way. This report reviews 401 liver biopsies in 312 patients. The major indications for use of this procedure are: To determine the cause of an obscure liver enlargement; to establish the cause of jaundice; to distinguish between malignant disease and cirrhosis of the liver; to determine when hepatitis has subsided; and to evaluate the results of treatment. At times, systemic disease that has not been recognized by other means may be diagnosed by this technique. There is risk in performing this test, and the 0.25 per cent mortality in this series compares favorably with that reported from other clinics. Where the diagnosis by biopsy could be compared with observations at operation or autopsy, the correct diagnosis was made by biopsy in 85 per cent of cases. Greater accuracy was obtained by two or more biopsic examinations in one case then by single biopsy. In several cases in which surgical operation was considered, biopsic information made it unnecessary, and vice versa. PMID:14886754

On the use of pulsed Dielectric Barrier Discharges to control the gas-phase composition of atmospheric pressure air plasmas

NASA Astrophysics Data System (ADS)

Barni, R.; Biganzoli, I.; Dell'Orto, E.; Riccardi, C.

2014-11-01

We presents results obtained from the numerical simulation of the gas-phase chemical kinetics in atmospheric pressure air non-equilibrium plasmas. In particular we have addressed the effect of pulsed operation mode of a plane dielectric barrier discharge. It was conjectured that the large difference in the time scales involved in the fast dissociation of oxygen molecules in plasma and their subsequent reactions to produce ozone and nitrogen oxides, makes the presence of a continuously repeated plasma production unnecessary and a waste of electrical power and thus efficiency. In order to test such suggestion we have performed a numerical study of the composition and the temporal evolution of the gas-phase of atmospheric pressure air non-equilibrium plasmas. Comparison with experimental findings in a dielectric barrier discharge with an electrode configuration symmetrical and almost ideally plane is briefly addressed too, using plasma diagnostics to extract the properties of the single micro-discharges and a sensor to measure the concentration of ozone produced by the plasma.

Improving outcome of trauma patients by implementing patient blood management.

PubMed

Füllenbach, Christoph; Zacharowski, Kai; Meybohm, Patrick

2017-04-01

Patient blood management aims to improve patient outcome and safety by reducing the number of unnecessary red blood cell transfusions and vitalizing patient-specific anemia reserves. While this is increasingly recognized as best clinical practice in elective surgery, the implementation in the setting of trauma is restrained because of typically nonelective (emergency) surgery and, in specific circumstances, allogeneic blood transfusions as life-saving therapy. Viscoelastic diagnostics allow a precise identification of trauma-induced coagulopathy. A coagulation factor concentrate-based therapy is increasingly recognized as a fast and effective concept to correct coagulopathy and minimize blood loss. Using smaller tubes has a great potential to reduce the severity of phlebotomy-induced anemia. Washed cell salvage may reduce the number of allogeneic blood transfusions. Intravenous iron (with or without erythropoietin) may result in an increase of hemoglobin levels and reduced red blood cell transfusion requirements. Although a restrictive transfusion strategy is recommended in general, a target hemoglobin level of 7-9 g/dl is recommended in acute bleeding patients. In the setting of trauma, options to avoid unnecessary blood loss and reduce blood transfusion are manifold. These are likely to improve safety and outcome of trauma patients while potentially reducing therapeutic costs.

Budget impact analysis of sFlt-1/PlGF ratio as prediction test in Italian women with suspected preeclampsia.

PubMed

Frusca, Tiziana; Gervasi, Maria-Teresa; Paolini, Davide; Dionisi, Matteo; Ferre, Francesca; Cetin, Irene

2017-09-01

Preeclampsia (PE) is a pregnancy disease which represents a leading cause of maternal and perinatal mortality and morbidity. Accurate prediction of PE risk could provide an increase in health benefits and better patient management. To estimate the economic impact of introducing Elecsys sFlt-1/PlGF ratio test, in addition to standard practice, for the prediction of PE in women with suspected PE in the Italian National Health Service (INHS). A decision tree model has been developed to simulate the progression of a cohort of pregnant women from the first presentation of clinical suspicion of PE in the second and third trimesters until delivery. The model provides an estimation of the financial impact of introducing sFlt-1/PlGF versus standard practice. Clinical inputs have been derived from PROGNOSIS study and from literature review, and validated by National Clinical Experts. Resources and unit costs have been obtained from Italian-specific sources. Healthcare costs associated with the management of a pregnant woman with clinical suspicion of PE equal €2384 when following standard practice versus €1714 using sFlt-1/PlGF ratio test. Introduction of sFlt-1/PlGF into hospital practice is cost-saving. Savings are generated primarily through improvement in diagnostic accuracy and reduction in unnecessary hospitalization for women before PE's onset.

Men's preferences and trade-offs for prostate cancer screening: a discrete choice experiment.

PubMed

Howard, Kirsten; Salkeld, Glenn P; Patel, Manish I; Mann, Graham J; Pignone, Michael P

2015-12-01

Prostate cancer screening using prostate-specific antigen (PSA) remains controversial. In deciding about screening, men must weigh the benefits and harms: little is known about benefit: harm trade-offs men are willing to accept. The objective of this study was to assess men's preferences for PSA screening, and the trade-offs between benefits and harms men are willing to accept when deciding about screening. Preferences of 662 men aged 40-69 were assessed using a discrete choice experiment. PSA screening was described by six attributes: prostate cancer deaths, prostate cancer diagnoses, unnecessary biopsies from false-positive PSA tests, impotence, urinary incontinence/bowel problems and cost. A mixed logit model was used to examine the influence of attributes on men's preferences for PSA testing; benefit: harm trade-offs were also calculated. Men's preferences were significantly influenced by test characteristics, particularly potential mortality benefit, unnecessary biopsies and likelihood of urinary incontinence or bowel problems; preferences were also influenced by age, prior PSA testing experience and perceived risk of prostate cancer. Men were willing to accept between 65 and 233 of 10 000 extra men with unnecessary biopsies, and between 31 and 72 of 10 000 extra men with incontinence/bowel problems to avoid one prostate cancer death. Differences in valuations of attributes and trade-offs acceptable to men of different ages suggest a one size fits all approach to PSA testing, regardless of age, may not reflect men's preferences. Our results can be used by policymakers to ensure screening programmes are in line with men's preferences and by clinicians and patients to facilitate informed discussions of the most relevant benefits and downsides of PSA screening for an individual man. © 2014 John Wiley & Sons Ltd.

5 CFR 315.608 - Noncompetitive appointment of certain former overseas employees.

Code of Federal Regulations, 2011 CFR

2011-01-01

... written test after determining that the duties and responsibilities of the applicant's overseas position were similar enough to make the written test unnecessary. (1) Tenure. A person appointed under this... individual, for example, ill health or personal interest in relocating. (d) Time limit on eligibility. An...

5 CFR 315.608 - Noncompetitive appointment of certain former overseas employees.

Code of Federal Regulations, 2013 CFR

2013-01-01

... written test after determining that the duties and responsibilities of the applicant's overseas position were similar enough to make the written test unnecessary. (1) Tenure. A person appointed under this... individual, for example, ill health or personal interest in relocating. (d) Time limit on eligibility. An...

Mayo Clinic employees responded to new requirements for cost sharing by reducing possibly unneeded health services use.

PubMed

Shah, Nilay D; Naessens, James M; Wood, Douglas L; Stroebel, Robert J; Litchy, William; Wagie, Amy; Fan, Jiaquan; Nesse, Robert

2011-11-01

Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20 percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.

Canine Distemper Virus Antigen Detection in External Epithelia of Recently Vaccinated, Sick Dogs by Fluorescence Microscopy Is a Valuable Prognostic Indicator

PubMed Central

Neel, Tina

2014-01-01

Currently, there are no reliable predictors of the clinical outcomes of domesticated dogs that have been recently vaccinated against canine distemper virus (CDV) and develop respiratory disease. In this study, vaccinated dogs from Oklahoma City that were showing clinical signs of respiratory disease were evaluated for CDV antigen using a direct fluorescent antibody test (FAT). Clinical outcomes after standard symptomatic therapy for respiratory disease were recorded, and a statistical analysis of the results was performed. We present our study showing that CDV FAT results were predictive of clinical recovery (prognostic indicator, prospects of clinical recovery) among vaccinated dogs showing clinical signs of respiratory disease. Negative CDV FAT results equated to 80% chances of recovery after symptomatic therapy, compared to 55% chances of recovery when the CDV FAT results were positive. Based on the results of this study, we show that veterinarians can make better informed decisions about the clinical outcomes of suspected CDV cases, with 2-h turnaround times, by using the CDV FAT. Thus, antemortem examination with the CDV FAT on external epithelia of recently vaccinated, sick dogs is a clinically useful diagnostic test and valuable prognostic indicator for veterinarians. Application of the CDV FAT to these samples avoids unnecessary euthanasia of dogs with suspected CDV. PMID:25428156

Pseudothrombocytopenia or platelet clumping as a possible cause of low platelet count in patients with viral infection: a case series from single institution focusing on hepatitis A virus infection.

PubMed

Choe, W-H; Cho, Y-U; Chae, J-D; Kim, S-H

2013-02-01

Pseudothrombocytopenia (PTCP) is the phenomenon of ethylenediaminetetraacetic acid anticoagulant-activated platelet clumping, which results in artificially low platelet counts. Other investigators have reported a few cases of PTCP associated with viral infections. The objective of this study was to demonstrate the association of viral infection with PTCP. Medical records of patients with thrombocytopenia who were tested for peripheral blood smear examination between March 2009 and February 2011 were reviewed for platelet clumping and viral infection. Thrombocytopenic patients with viral infection had a higher frequency of platelet clumping than those with other diseases, which was statistically significant (13.8% vs. 6.5%, respectively: P = 0.003). Among the 18 cases where PTCP or platelet clumping was related to viral infection, hepatitis A virus infection (72.2%) was most common, followed by cytomegalovirus (11.1%) and influenza A H1N1 infections (5.6%). A third (33.3%) of the patients had platelet counts <100 × 10⁹/L. Pseudothrombocytopenia or platelet clumping should be considered in patients with acute viral infection, particularly if the platelet count is unexpectedly low, because failure to recognize PTCP may lead to unnecessary diagnostic tests and patient mismanagement. © 2012 Blackwell Publishing Ltd.

Responses to Bacteria, Virus, and Malaria Distinguish the Etiology of Pediatric Clinical Pneumonia.

PubMed

Valim, Clarissa; Ahmad, Rushdy; Lanaspa, Miguel; Tan, Yan; Acácio, Sozinho; Gillette, Michael A; Almendinger, Katherine D; Milner, Danny A; Madrid, Lola; Pellé, Karell; Harezlak, Jaroslaw; Silterra, Jacob; Alonso, Pedro L; Carr, Steven A; Mesirov, Jill P; Wirth, Dyann F; Wiegand, Roger C; Bassat, Quique

2016-02-15

Plasma-detectable biomarkers that rapidly and accurately diagnose bacterial infections in children with suspected pneumonia could reduce the morbidity of respiratory disease and decrease the unnecessary use of antibiotic therapy. Using 56 markers measured in a multiplexed immunoassay, we sought to identify proteins and protein combinations that could discriminate bacterial from viral or malarial diagnoses. We selected 80 patients with clinically diagnosed pneumonia (as defined by the World Health Organization) who also met criteria for bacterial, viral, or malarial infection based on clinical, radiographic, and laboratory results. Ten healthy community control subjects were enrolled to assess marker reliability. Patients were subdivided into two sets: one for identifying potential markers and another for validating them. Three proteins (haptoglobin, tumor necrosis factor receptor 2 or IL-10, and tissue inhibitor of metalloproteinases 1) were identified that, when combined through a classification tree signature, accurately classified patients into bacterial, malarial, and viral etiologies and misclassified only one patient with bacterial pneumonia from the validation set. The overall sensitivity and specificity of this signature for the bacterial diagnosis were 96 and 86%, respectively. Alternative combinations of markers with comparable accuracy were selected by support vector machine and regression models and included haptoglobin, IL-10, and creatine kinase-MB. Combinations of plasma proteins accurately identified children with a respiratory syndrome who were likely to have bacterial infections and who would benefit from antibiotic therapy. When used in conjunction with malaria diagnostic tests, they may improve diagnostic specificity and simplify treatment decisions for clinicians.

ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain.

PubMed

Zuin, Guerrino; Parato, Vito Maurizio; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto di Uccio, Fortunato; Valente, Serafina

2017-05-01

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain

PubMed Central

Zuin, Guerrino; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto di Uccio, Fortunato; Valente, Serafina

2017-01-01

Abstract Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country. PMID:28751843

[ANMCO/SIMEU Consensus document: In-hospital management of patients presenting with chest pain].

PubMed

Zuin, Guerrino; Parato, Vito Maurizio; Groff, Paolo; Gulizia, Michele Massimo; Di Lenarda, Andrea; Cassin, Matteo; Cibinel, Gian Alfonso; Del Pinto, Maurizio; Di Tano, Giuseppe; Nardi, Federico; Rossini, Roberta; Ruggieri, Maria Pia; Ruggiero, Enrico; Scotto Di Uccio, Fortunato; Valente, Serafina

2016-06-01

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: 1) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; 2) the increasing percentage of hospitalizations of low-risk cases.It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Cytological Diagnosis of Primary Thyroid Tuberculosis.

PubMed

Goyal, P; Mittal, D; Ghosh, S; Agrawal, D; Sehgal, S; Singh, S

2015-01-01

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Unusual presentation of a familiar pathology: chronic appendicitis.

PubMed

Sierakowski, Kyra; Pattichis, Andrew; Russell, Patrick; Wattchow, David

2016-02-11

We present a case of a man who experienced night sweats, abdominal pain and fever for over 3 months, with incomplete response to broad-spectrum intravenous antibiotics. Although CT imaging was insufficient to identify the cause for his chronic abdominal pain, the abnormality of a 'misty mesentery' was crucial in guiding further investigation. The final diagnosis of chronic appendicitis was made through laparoscopic and pathological examination. This case highlights the utility of a collaborative diagnostic effort between disciplines. Chronic appendicitis can cause lingering abdominal pain. Early recognition and appropriate referral can save patients months and even years of unnecessary suffering. 2016 BMJ Publishing Group Ltd.

Uterine Vascular Lesions

PubMed Central

Vijayakumar, Abhishek; Srinivas, Amruthashree; Chandrashekar, Babitha Moogali; Vijayakumar, Avinash

2013-01-01

Vascular lesions of the uterus are rare; most reported in the literature are arteriovenous malformations (AVMs). Uterine AVMs can be congenital or acquired. In recent years, there has been an increasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, cesarean delivery, and curettage. It can be seen from these reports that there is confusion concerning the terminology of uterine vascular lesions. There is also a lack of diagnostic criteria and management guidelines, which has led to an increased number of unnecessary invasive procedures (eg, angiography, uterine artery embolization, hysterectomy for abnormal vaginal bleeding). This article familiarizes readers with various vascular lesions of the uterus and their management. PMID:24340126

Hot Tub Folliculitis: A Clinical Syndrome

PubMed Central

Zacherle, Barry J.; Silver, Diane S.

1982-01-01

With the increasing use of hot tubs, patients are being seen with a distinct clinical syndrome that appears several hours or days after hot tub exposure. It consists of a maculovesicular, often pruritic rash, and commonly occurring associated symptoms including fever, upper respiratory tract complaints, axillary adenopathy and breast tenderness. Cultures in the cases described here grew out Pseudomonas aeruginosa, giving a diagnosis of Pseudomonas folliculitis. The illness clears spontaneously without any treatment. Proper attention to hot tub chlorination and use are probably important in preventing this problem, and awareness of the syndrome by physicians may prevent unnecessary and costly diagnostic studies and treatment programs. PMID:7147933

Reducing Unnecessary and Duplicate Ordering for Ovum and Parasite Examinations and Clostridium difficile PCR in Immunocompromised Patients by Using an Alert at the Time of Request in the Order Management System.

PubMed

Otto, Caitlin C; Shuptar, Susan L; Milord, Philippe; Essick, Connor J; Nevrekar, Reshma; Granovsky, Svetlana L; Seo, Susan K; Babady, N Esther; Martin, Steven C; Tang, Yi-Wei; Pessin, Melissa S

2015-08-01

We implemented hospital information system (HIS) alerts to deter unnecessary test orders for ovum and parasite (O&P) exams and Clostridium difficile PCR. The HIS alerts decreased noncompliant O&P orders (orders after >72 h of hospitalization) from 49.8% to 30.9%, an overall decrease of 19%, and reduced noncompliant C. difficile PCR orders (orders <7 days after a previous positive result) from 30.6% to 19.2%, an overall decrease of 31.9%. Copyright © 2015, American Society for Microbiology. All Rights Reserved.

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

PubMed Central

Xu, Min Li; Lopez, Joseph

2016-01-01

Background: Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center. Methods: We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes. Results: There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients. Conclusions: The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients. PMID:26877626

Computed tomography and patient risk: Facts, perceptions and uncertainties

PubMed Central

Power, Stephen P; Moloney, Fiachra; Twomey, Maria; James, Karl; O’Connor, Owen J; Maher, Michael M

2016-01-01

Since its introduction in the 1970s, computed tomography (CT) has revolutionized diagnostic decision-making. One of the major concerns associated with the widespread use of CT is the associated increased radiation exposure incurred by patients. The link between ionizing radiation and the subsequent development of neoplasia has been largely based on extrapolating data from studies of survivors of the atomic bombs dropped in Japan in 1945 and on assessments of the increased relative risk of neoplasia in those occupationally exposed to radiation within the nuclear industry. However, the association between exposure to low-dose radiation from diagnostic imaging examinations and oncogenesis remains unclear. With improved technology, significant advances have already been achieved with regards to radiation dose reduction. There are several dose optimization strategies available that may be readily employed including omitting unnecessary images at the ends of acquired series, minimizing the number of phases acquired, and the use of automated exposure control as opposed to fixed tube current techniques. In addition, new image reconstruction techniques that reduce radiation dose have been developed in recent years with promising results. These techniques use iterative reconstruction algorithms to attain diagnostic quality images with reduced image noise at lower radiation doses. PMID:28070242

A novel serogenetic approach determines the community prevalence of celiac disease and informs improved diagnostic pathways.

PubMed

Anderson, Robert P; Henry, Margaret J; Taylor, Roberta; Duncan, Emma L; Danoy, Patrick; Costa, Marylia J; Addison, Kathryn; Tye-Din, Jason A; Kotowicz, Mark A; Knight, Ross E; Pollock, Wendy; Nicholson, Geoffrey C; Toh, Ban-Hock; Brown, Matthew A; Pasco, Julie A

2013-08-28

Changing perspectives on the natural history of celiac disease (CD), new serology and genetic tests, and amended histological criteria for diagnosis cast doubt on past prevalence estimates for CD. We set out to establish a more accurate prevalence estimate for CD using a novel serogenetic approach. The human leukocyte antigen (HLA)-DQ genotype was determined in 356 patients with 'biopsy-confirmed' CD, and in two age-stratified, randomly selected community cohorts of 1,390 women and 1,158 men. Sera were screened for CD-specific serology. Only five 'biopsy-confirmed' patients with CD did not possess the susceptibility alleles HLA-DQ2.5, DQ8, or DQ2.2, and four of these were misdiagnoses. HLA-DQ2.5, DQ8, or DQ2.2 was present in 56% of all women and men in the community cohorts. Transglutaminase (TG)-2 IgA and composite TG2/deamidated gliadin peptide (DGP) IgA/IgG were abnormal in 4.6% and 5.6%, respectively, of the community women and 6.9% and 6.9%, respectively, of the community men, but in the screen-positive group, only 71% and 75%, respectively, of women and 65% and 63%, respectively, of men possessed HLA-DQ2.5, DQ8, or DQ2.2. Medical review was possible for 41% of seropositive women and 50% of seropositive men, and led to biopsy-confirmed CD in 10 women (0.7%) and 6 men (0.5%), but based on relative risk for HLA-DQ2.5, DQ8, or DQ2.2 in all TG2 IgA or TG2/DGP IgA/IgG screen-positive subjects, CD affected 1.3% or 1.9%, respectively, of females and 1.3% or 1.2%, respectively, of men. Serogenetic data from these community cohorts indicated that testing screen positives for HLA-DQ, or carrying out HLA-DQ and further serology, could have reduced unnecessary gastroscopies due to false-positive serology by at least 40% and by over 70%, respectively. Screening with TG2 IgA serology and requiring biopsy confirmation caused the community prevalence of CD to be substantially underestimated. Testing for HLA-DQ genes and confirmatory serology could reduce the numbers of unnecessary gastroscopies.

Levelized cost-benefit analysis of proposed diagnostics for the Ammunition Transfer Arm of the US Army`s Future Armored Resupply Vehicle

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wilkinson, V.K.; Young, J.M.

1995-07-01

The US Army`s Project Manager, Advanced Field Artillery System/Future Armored Resupply Vehicle (PM-AFAS/FARV) is sponsoring the development of technologies that can be applied to the resupply vehicle for the Advanced Field Artillery System. The Engineering Technology Division of the Oak Ridge National Laboratory has proposed adding diagnostics/prognostics systems to four components of the Ammunition Transfer Arm of this vehicle, and a cost-benefit analysis was performed on the diagnostics/prognostics to show the potential savings that may be gained by incorporating these systems onto the vehicle. Possible savings could be in the form of reduced downtime, less unexpected or unnecessary maintenance, fewermore » regular maintenance checks. and/or tower collateral damage or loss. The diagnostics/prognostics systems are used to (1) help determine component problems, (2) determine the condition of the components, and (3) estimate the remaining life of the monitored components. The four components on the arm that are targeted for diagnostics/prognostics are (1) the electromechanical brakes, (2) the linear actuators, (3) the wheel/roller bearings, and (4) the conveyor drive system. These would be monitored using electrical signature analysis, vibration analysis, or a combination of both. Annual failure rates for the four components were obtained along with specifications for vehicle costs, crews, number of missions, etc. Accident scenarios based on component failures were postulated, and event trees for these scenarios were constructed to estimate the annual loss of the resupply vehicle, crew, arm. or mission aborts. A levelized cost-benefit analysis was then performed to examine the costs of such failures, both with and without some level of failure reduction due to the diagnostics/prognostics systems. Any savings resulting from using diagnostics/prognostics were calculated.« less

Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis.

PubMed

Karel, Yasmaine H J M; Verkerk, Karin; Endenburg, Silvio; Metselaar, Sven; Verhagen, Arianne P

2015-10-01

The increasing use of diagnostic imaging has led to high expenditures, unnecessary invasive procedures and/or false-positive diagnoses, without certainty that the patients actually benefit from these imaging procedures. This review explores whether diagnostic imaging leads to better patient-reported outcomes in individuals with musculoskeletal disorders. Databases were searched from inception to September 2013, together with scrutiny of selected bibliographies. Trials were eligible when: 1) a diagnostic imaging procedure was compared with any control group not getting or not receiving the results of imaging; 2) the population included individuals suffering from musculoskeletal disorders, and 3) if patient-reported outcomes were available. Primary outcome measures were pain and function. Secondary outcome measures were satisfaction and quality of life. Subgroup analysis was done for different musculoskeletal complaints and high technological medical imaging (MRI/CT). Eleven trials were eligible. The effects of diagnostic imaging were only evaluated in patients with low back pain (n=7) and knee complaints (n=4). Overall, there was a moderate level of evidence for no benefit of diagnostic imaging on all outcomes compared with controls. A significant but clinically irrelevant effect was found in favor of no (routine) imaging in low back pain patients in terms of pain severity at short [SMD 0.17 (0.04-0.31)] and long-term follow-up [SMD 0.13 (0.02-0.24)], and for overall improvement [RR 1.15 (1.03-1.28)]. Subgroup analysis did not significantly change these results. These results strengthen the available evidence that routine referral to diagnostic imaging by general practitioners for patients with knee and low back pain yields little to no benefit. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Introducing the reporting system for thyroid fine-needle aspiration cytology according to the new guidelines of the Japan Thyroid Association.

PubMed

Kakudo, Kennichi; Kameyama, Kaori; Miyauchi, Akira; Nakamura, Hirotoshi

2014-01-01

The Japan Thyroid Association (JTA) recently published new guidelines for clinical management of thyroid nodules. This paper introduces their diagnostic system for reporting thyroid fine-needle aspiration cytology. There are two points where the new reporting system that differs from existing internationally-accepted ones. The first is the subclassification of the so-called indeterminate category, which is divided into 'follicular neoplasm' and 'others'. The second is the subclassification of follicular neoplasm into 'favor benign', 'borderline' and 'favor malignant'. It is characterized by self-explanatory terminologies as to histological type and probability of malignancy to establish further risk stratification as well as to facilitate communication between clinicians and cytopathologists. The different treatment strategies adopted for thyroid nodules is deeply influenced by the particular diagnostic system used for thyroid cytology. In Western countries all patients with follicular neoplasms are advised to have immediate diagnostic surgery while patients in Japan often undergo further risk stratification without immediate surgery. The JTA diagnostic system of reporting thyroid cytology is designed for further risk stratification of patients with indeterminate cytology. If a surgeon applies diagnostic lobectomy to all patients with follicular neoplasm unselectively, this subclassification of follicular neoplasm has no practical meaning and is unnecessary. Cytological risk stratification of follicular neoplasms is optional and cytopathologists can choose either a simple 6-tier system without stratification of follicular neoplasm or a complicated 8-tier system depending on their experience in thyroid cytology and clinical management.

Goodness of Fit and Misspecification in Quantile Regressions

ERIC Educational Resources Information Center

Furno, Marilena

2011-01-01

The article considers a test of specification for quantile regressions. The test relies on the increase of the objective function and the worsening of the fit when unnecessary constraints are imposed. It compares the objective functions of restricted and unrestricted models and, in its different formulations, it verifies (a) forecast ability, (b)…

A stepwise algorithm using an at-a-glance first-line test for the non-invasive diagnosis of advanced liver fibrosis and cirrhosis.

PubMed

Boursier, Jérôme; de Ledinghen, Victor; Leroy, Vincent; Anty, Rodolphe; Francque, Sven; Salmon, Dominique; Lannes, Adrien; Bertrais, Sandrine; Oberti, Frederic; Fouchard-Hubert, Isabelle; Calès, Paul

2017-06-01

Chronic liver diseases (CLD) are common, and are therefore mainly managed by non-hepatologists. These physicians lack access to the best non-invasive tests of liver fibrosis, and consequently cannot accurately determine the disease severity. Referral to a hepatologist is then needed. We aimed to implement an algorithm, comprising a new first-line test usable by all physicians, for the detection of advanced liver fibrosis in all CLD patients. Diagnostic study: 3754 CLD patients with liver biopsy were 2:1 randomized into derivation and validation sets. Prognostic study: longitudinal follow-up of 1275 CLD patients with baseline fibrosis tests. Diagnostic study: the easy liver fibrosis test (eLIFT), an "at-a-glance" sum of points attributed to age, gender, gamma-glutamyl transferase, aspartate aminotransferase (AST), platelets and prothrombin time, was developed for the diagnosis of advanced fibrosis. In the validation set, eLIFT and fibrosis-4 (FIB4) had the same sensitivity (78.0% vs. 76.6%, p=0.470) but eLIFT gave fewer false positive results, especially in patients ≥60years old (53.8% vs. 82.0%, p<0.001), and was thus more suitable as screening test. FibroMeter with vibration controlled transient elastography (VCTE) was the most accurate among the eight fibrosis tests evaluated. The sensitivity of the eLIFT-FM VCTE algorithm (first-line eLIFT, second-line FibroMeter VCTE ) was 76.1% for advanced fibrosis and 92.1% for cirrhosis. Prognostic study: patients diagnosed as having "no/mild fibrosis" by the algorithm had excellent liver-related prognosis with thus no need for referral to a hepatologist. The eLIFT-FM VCTE algorithm extends the detection of advanced liver fibrosis to all CLD patients and reduces unnecessary referrals of patients without significant CLD to hepatologists. Blood fibrosis tests and transient elastography accurately diagnose advanced liver fibrosis in the large population of patients having chronic liver disease, but these non-invasive tests are only currently available in specialized centers. We have developed an algorithm including the easy liver fibrosis test (eLIFT), a new simple and widely available blood test. It is used as a first-line procedure that selects at-risk patients who need further evaluation with the FibroMeter VCTE , an accurate fibrosis test combining blood markers and transient elastography result. This new algorithm, called the eLIFT-FM VCTE , accurately identifies the patients with advanced chronic liver disease who need referral to a specialist, and those with no or mild liver lesions who can remain under the care of their usual physician. No registration (analysis of pooled data from previously published diagnostic studies). Copyright © 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Clinical effectiveness of a Bayesian algorithm for the diagnosis and management of heparin-induced thrombocytopenia.

PubMed

Raschke, R A; Gallo, T; Curry, S C; Whiting, T; Padilla-Jones, A; Warkentin, T E; Puri, A

2017-08-01

Essentials We previously published a diagnostic algorithm for heparin-induced thrombocytopenia (HIT). In this study, we validated the algorithm in an independent large healthcare system. The accuracy was 98%, sensitivity 82% and specificity 99%. The algorithm has potential to improve accuracy and efficiency in the diagnosis of HIT. Background Heparin-induced thrombocytopenia (HIT) is a life-threatening drug reaction caused by antiplatelet factor 4/heparin (anti-PF4/H) antibodies. Commercial tests to detect these antibodies have suboptimal operating characteristics. We previously developed a diagnostic algorithm for HIT that incorporated 'four Ts' (4Ts) scoring and a stratified interpretation of an anti-PF4/H enzyme-linked immunosorbent assay (ELISA) and yielded a discriminant accuracy of 0.97 (95% confidence interval [CI], 0.93-1.00). Objectives The purpose of this study was to validate the algorithm in an independent patient population and quantitate effects that algorithm adherence could have on clinical care. Methods A retrospective cohort comprised patients who had undergone anti-PF4/H ELISA and serotonin release assay (SRA) testing in our healthcare system from 2010 to 2014. We determined the algorithm recommendation for each patient, compared recommendations with the clinical care received, and enumerated consequences of discrepancies. Operating characteristics were calculated for algorithm recommendations using SRA as the reference standard. Results Analysis was performed on 181 patients, 10 of whom were ruled in for HIT. The algorithm accurately stratified 98% of patients (95% CI, 95-99%), ruling out HIT in 158, ruling in HIT in 10 and recommending an SRA in 13 patients. Algorithm adherence would have obviated 165 SRAs and prevented 30 courses of unnecessary antithrombotic therapy for HIT. Diagnostic sensitivity was 0.82 (95% CI, 0.48-0.98), specificity 0.99 (95% CI, 0.97-1.00), PPV 0.90 (95% CI, 0.56-0.99) and NPV 0.99 (95% CI, 0.96-1.00). Conclusions An algorithm incorporating 4Ts scoring and a stratified interpretation of the anti-PF4/H ELISA has good operating characteristics and the potential to improve management of suspected HIT patients. © 2017 International Society on Thrombosis and Haemostasis.

Suspected Testosterone-Producing Tumor in a Patient Taking Biotin Supplements

PubMed Central

Stieglitz, Heather M; Korpi-Steiner, Nichole; Katzman, Brooke; Mersereau, Jennifer E; Styner, Maya

2018-01-01

Abstract A perimenopausal woman presented with palpitations, hirsutism, and inability to lose weight. Laboratory tests revealed an unusual endocrine hormonal profile including pituitary hormones (TSH, ACTH, and prolactin) below reference intervals and gonadal (testosterone) and adrenal (cortisol) hormones above reference intervals. Ultimately, after a comprehensive workup including a scheduled surgical procedure, abnormal laboratories were determined due to biotin interference. Biotin (vitamin B7) is a water-soluble vitamin and essential cofactor for the metabolism of fatty acids, glucose, and amino acids. The recommended daily intake of biotin for adults is 30 µg/d. Many over-the-counter products, particularly those marketed for hair, skin, and nail growth, contain biotin 100-fold of recommended daily intake. This case is unique due to the abnormalities observed not only in the well-described TSH “sandwich” immunoassay, but also in tests for gonadal steroids, adrenal, and pituitary hormones. Falsely high as well as falsely low results can be ascribed to biotin. Competitive immunoassays (Fig. 1A)— in this case, tests used initially for serum cortisol and testosterone— can demonstrate falsely high results. Interference falsely lowers the immunometric “sandwich” immunoassay (Fig. 1B)—in this case, TSH. Biotin effect on our patient’s endocrine testing led to decidedly abnormal findings, unnecessary medical referrals and diagnostic studies, and comprehensible psychological distress. Interference with one immunoassay, TSH, persisted a full 2 weeks after discontinuation of biotin; indeed, some tests demonstrate sensitivity to lesser quantities of biotin. Improved communication between patients, health care providers, and laboratory professionals is required concerning the likelihood of biotin interference with immunoassays.

Frequency of Unnecessarily Biopsies among Patients with Suspicion of Prostate Cancer in Syrian Men.

PubMed

Bachour, Dala-Maria; Chahin, Emil; Al-Fahoum, Sahar

2015-01-01

The prevalence of prostate cancer is considered high in many countries, and screening tests are very important in order to detect prostate cancer in its early stages; however false positivity with these screening tests means that a lot of patients undergo unnecessary biopsy, which is an invasive procedure, for the confirmatory test. The purpose of this study was to estimate the frequency of unnecessary biopsy cases in patients referred for prostate biopsy in one of the most important and overload cancer centers in Syria. Retrospective data for a period of four years between January 2009 and December 2012 were collected in Al- Bayrouni University Medical hospital in Damascus, Syria. The patients from whom data were collected were referred to our histopathological department because of elevated prostate specific antigen (PSA) serum or an abnormal digital rectal examination (DRE). All patients underwent prostatic TRUS-guided biopsies. Diagnosis of prostate cancer (PCa) or benign prostatic hyperplasia (BPH) was based on histopathological examination and prostate cancers cases were graded and scored according to the Gleason score system. For the 406 patients referred to biopsy, the mean±SD age was 58.4 ±23.3 years. The mean ± SD PSA level was 49.2±21.5 ng/ ml. Of the total we found 237 patients diagnosed with PCa (58. 4%), 166 patients with BPH (40.9%) and 3 cases were unable to be diagnosed (0.7%) because of biopsy collection errors. Our study shows that a high percentage of patients are undergoing unnecessary biopsy, which suggests that the performed screening tests had a high level of false positive and may need re-evaluation.

Reduced Clostridium difficile Tests and Laboratory-Identified Events With a Computerized Clinical Decision Support Tool and Financial Incentive.

PubMed

Madden, Gregory R; German Mesner, Ian; Cox, Heather L; Mathers, Amy J; Lyman, Jason A; Sifri, Costi D; Enfield, Kyle B

2018-06-01

We hypothesized that a computerized clinical decision support tool for Clostridium difficile testing would reduce unnecessary inpatient tests, resulting in fewer laboratory-identified events. Census-adjusted interrupted time-series analyses demonstrated significant reductions of 41% fewer tests and 31% fewer hospital-onset C. difficile infection laboratory-identified events following this intervention.Infect Control Hosp Epidemiol 2018;39:737-740.

Detection of tanker defects with infrared thermography

NASA Technical Reports Server (NTRS)

Kantsios, A. G.

1980-01-01

Infrared scanning technique for finding defects in secondary barrier of liquid natural gas (LNG) tank has been successfully tested on ship under construction at Newport News Shipbuilding and Dry Dock Company. Technique determines defects with minimal expenditure of time and manpower. Tests could be repeated during life of tanker and make more complicated testing unnecessary. Tests also confirmed that tank did not have any major defects, and tank was certified.

Evaluating compliance with institutional preoperative testing guidelines for minimal-risk patients undergoing elective surgery.

PubMed

Siriussawakul, Arunotai; Nimmannit, Akarin; Rattana-arpa, Sirirat; Chatrattanakulchai, Siritda; Saengtawan, Puttachard; Wangdee, Aungsumat

2013-01-01

Few investigations preoperatively are important for low-risk patients. This study was designed to determine the level of compliance with preoperative investigation guidelines for ASA I patients undergoing elective surgery. Secondary objectives included the following: to identify common inappropriate investigations, to evaluate the impact of abnormal testing on patient management, to determine factors affecting noncompliant tests, and to estimate unnecessary expenditure. This retrospective study was conducted on adult patients over a one-year period. The institute's guidelines recommend tests according to the patients' age groups: a complete blood count (CBC) for those patients aged 18-45; CBC, chest radiograph (CXR) and electrocardiography (ECG) for those aged 46-60; and CBC, CXR, ECG, electrolytes, blood glucose, blood urea nitrogen (BUN), and creatinine (Cr) for patients aged 61-65. The medical records of 1,496 patients were reviewed. Compliant testing was found in only 12.1% (95% CI, 10.5-13.9). BUN and Cr testings were the most frequently overprescribed tests. Overinvestigations tended to be performed on major surgery and younger patients. Overall, overinvestigation incurred an estimated cost of US 200,000 dollars during the study period. The need to utilize the institution's preoperative guidelines should be emphasized in order to decrease unnecessary testing and the consequential financial burden.

Impact of the implementation of an evidence-based guideline on diagnostic testing, management, and clinical outcomes for infants with bronchiolitis

PubMed Central

Henao-Villada, Ricardo; Sossa-Briceño, Monica P.; Rodríguez-Martínez, Carlos E.

2016-01-01

Background: Although bronchiolitis poses a significant health problem in low- and middle-income countries (LMICs), to the best of our knowledge, to date it has not been determined whether evidence-based bronchiolitis clinical practice guidelines (CPGs) complemented by standardized educational strategies reduce the use of unnecessary diagnostic tests and medications and improve clinically important outcomes in LMICs. Methods: In an uncontrolled before and after study, we assessed the impact of the implementation of an evidence-based bronchiolitis CPG on physician behavior and the care of infants with bronchiolitis by comparing pre-guideline (March to August 2014) and post-guideline (March to August 2015) use of diagnostic tests and medications through an electronic medical record review in a children’s hospital in Bogota, Colombia. We also sought to assess the impact of the implementation of the CPG on clinically important outcomes such as lengths of stay, hospital admissions, intensive care admissions, and hospital readmissions. Results: Data from 662 cases of bronchiolitis (pre-guideline period) were compared with the data from 703 cases (post-guideline period). On comparing the pre- and post-guideline periods, it was seen that there was a significant increase in the proportion of patients with an appropriate diagnosis and treatment of bronchiolitis (36.4% versus 44.5%, p = 0.003), and there were statistically significant decreases in the use of a hemogram (33.2% versus 26.6%, p=0.010), procalcitonin (3.9% versus 1.6%, p=0.018), nebulized beta-2 agonists (45.6% versus 3.4%, p < 0.001), nebulized anticholinergics (3.3% versus 1.4%, p= 0.029), and nebulized epinephrine (16.2% versus 7.8%, p < 0.001). Likewise, a significant increase in the use of nebulized hypertonic saline was seen (79.6% versus 91.7%, p < 0.001). However, implementation of the CPG for bronchiolitis was not associated with significant changes in clinically important outcomes. Conclusions: The development and implementation of a good quality bronchiolitis CPG is associated with a significant increase in the proportion of cases with an appropriate diagnosis and treatment of the disease in the context of a university-based hospital located in the capital of an LMIC. However, we could not demonstrate an improvement in clinically important outcomes such as any of the bronchiolitis severity parameters. PMID:27492738

Development of a clinical decision model for thyroid nodules

PubMed Central

Stojadinovic, Alexander; Peoples, George E; Libutti, Steven K; Henry, Leonard R; Eberhardt, John; Howard, Robin S; Gur, David; Elster, Eric A; Nissan, Aviram

2009-01-01

Background Thyroid nodules represent a common problem brought to medical attention. Four to seven percent of the United States adult population (10–18 million people) has a palpable thyroid nodule, however the majority (>95%) of thyroid nodules are benign. While, fine needle aspiration remains the most cost effective and accurate diagnostic tool for thyroid nodules in current practice, over 20% of patients undergoing FNA of a thyroid nodule have indeterminate cytology (follicular neoplasm) with associated malignancy risk prevalence of 20–30%. These patients require thyroid lobectomy/isthmusectomy purely for the purpose of attaining a definitive diagnosis. Given that the majority (70–80%) of these patients have benign surgical pathology, thyroidectomy in these patients is conducted principally with diagnostic intent. Clinical models predictive of malignancy risk are needed to support treatment decisions in patients with thyroid nodules in order to reduce morbidity associated with unnecessary diagnostic surgery. Methods Data were analyzed from a completed prospective cohort trial conducted over a 4-year period involving 216 patients with thyroid nodules undergoing ultrasound (US), electrical impedance scanning (EIS) and fine needle aspiration cytology (FNA) prior to thyroidectomy. A Bayesian model was designed to predict malignancy in thyroid nodules based on multivariate dependence relationships between independent covariates. Ten-fold cross-validation was performed to estimate classifier error wherein the data set was randomized into ten separate and unique train and test sets consisting of a training set (90% of records) and a test set (10% of records). A receiver-operating-characteristics (ROC) curve of these predictions and area under the curve (AUC) were calculated to determine model robustness for predicting malignancy in thyroid nodules. Results Thyroid nodule size, FNA cytology, US and EIS characteristics were highly predictive of malignancy. Cross validation of the model created with Bayesian Network Analysis effectively predicted malignancy [AUC = 0.88 (95%CI: 0.82–0.94)] in thyroid nodules. The positive and negative predictive values of the model are 83% (95%CI: 76%–91%) and 79% (95%CI: 72%–86%), respectively. Conclusion An integrated predictive decision model using Bayesian inference incorporating readily obtainable thyroid nodule measures is clinically relevant, as it effectively predicts malignancy in thyroid nodules. This model warrants further validation testing in prospective clinical trials. PMID:19664278

Comparison of the effectiveness of a PAMG-1 test and standard clinical assessment in the prediction of preterm birth and reduction of unnecessary hospital admissions.

PubMed

Lotfi, Ghassan; Faraz, Saima; Nasir, Razan; Somini, Sreenisha; Abdeldayem, Rasha M; Koratkar, Raghunandini; Alsawalhi, Nadia; Ammar, Abeer

2017-10-26

The purpose of this study is to first compare the performance of the PAMG-1 biomarker test to that of standard clinical assessment (SCA) for the risk assessment of spontaneous preterm delivery (sPTD) among women with symptoms of preterm labor (PTL) and then calculate the potential impact on unnecessary admission reduction. Patients of gestational age 24 0/7 -36 6/7 with PTL symptoms, cervical dilatation ≤3 cm, no intercourse within 24 h, and clinically intact membranes were recruited consecutively into this prospective observational study. Specificity (SP), sensitivity (SN), positive-predictive value (PPV), and negative-predictive value (NPV) for the PAMG-1 test and SCA, for which a positive result was defined as patient admission, for predicting spontaneous delivery ≤7 and ≤14 d of presentation were calculated. One hundred and forty-eight patients were included in the analysis, 132 of which had both SCA and PAMG-1 results available. For the prediction of sPTD ≤7 d for SCA and PAMG-1, the PPV and NPV were 10% and 100%, and 71% and 98%, respectively. For prediction of sPTD ≤14 d for SCA and PAMG-1, the PPV and NPV were 14% and 100%, and 86% and 96%, respectively. Sixty-one per cent (81/132) of patients were admitted for treatment and/or observation. Our study reinforces the critical role of the PAMG-1 biomarker test to aid in risk assessment of imminent spontaneous preterm delivery in patients with symptoms of PTL. The PAMG-1 test was found to be statistically superior to standard clinical assessment alone, with respect to specificity. Based on our data, the introduction of a PAMG-1 test result into clinical decision making could reduce up to 91% of unnecessary admissions for women presenting with threatened preterm labor.

Putting a New Filter On Cancer Screening.

PubMed

Huff, Charlotte

2016-10-01

Experts are rethinking routine cancer screening. Genetic tests could be the answer. They may add upfront expense, but might eventually lead to savings by winnowing out unnecessary screening. Concern about false positives helps push this movement along.

Mold Testing or Sampling

EPA Pesticide Factsheets

In most cases, if visible mold growth is present, sampling is unnecessary. Since no EPA or other federal limits have been set for mold or mold spores, sampling cannot be used to check a building's compliance with federal mold standards.

Migraine headache in patients with idiopathic intracranial hypertension.

PubMed

Sina, Farzad; Razmeh, Saeed; Habibzadeh, Neda; Zavari, Arefeh; Nabovvati, Mona

2017-08-29

Migraine is a neurological disorder that afflicts many people in the world and can cause severe disability during the attacks. The pathophysiology of migraine is complex and not fully understood. It seems that migraine is common in idiopathic intracranial hypertension (IIH). However, the association between migraine headache and IIH is still unclear. The present study was conducted to assess the prevalence of migraine headache and associated factors in IIH patients. In this cross-sectional study, a total of 68 patients diagnosed with IIH underwent a medical history interview and a neurological examination. The diagnosis of migraine was based on the four diagnostic criteria of the International Classification of Headache Disorders 3rd edition. Forty-five patients (63.2%) met the diagnostic criteria of migraine headache. There was no significant difference between patients with and without migraine headache in respect of their age, gender, body mass. This study revealed high prevalence of migraine headache in IIH patients; appropriate treatment can reduce their headache and prevent unnecessary treatments for IIH.

Migraine headache in patients with idiopathic intracranial hypertension

PubMed Central

Sina, Farzad; Razmeh, Saeed; Habibzadeh, Neda; Zavari, Arefeh; Nabovvati, Mona

2017-01-01

Migraine is a neurological disorder that afflicts many people in the world and can cause severe disability during the attacks. The pathophysiology of migraine is complex and not fully understood. It seems that migraine is common in idiopathic intracranial hypertension (IIH). However, the association between migraine headache and IIH is still unclear. The present study was conducted to assess the prevalence of migraine headache and associated factors in IIH patients. In this cross-sectional study, a total of 68 patients diagnosed with IIH underwent a medical history interview and a neurological examination. The diagnosis of migraine was based on the four diagnostic criteria of the International Classification of Headache Disorders 3rd edition. Forty-five patients (63.2%) met the diagnostic criteria of migraine headache. There was no significant difference between patients with and without migraine headache in respect of their age, gender, body mass. This study revealed high prevalence of migraine headache in IIH patients; appropriate treatment can reduce their headache and prevent unnecessary treatments for IIH. PMID:29071043

Dermoscopy, Digital Dermoscopy and Other Diagnostic Tools in the Early Detection of Melanoma and Follow-up of High-risk Skin Cancer Patients.

PubMed

Thomas, Luc; Puig, Susana

2017-07-05

Early detection is a key strategy for reducing the mortality and economic burden associated with melanoma. Dermoscopy is a non-invasive and cost-effective tool for melanoma diagnosis, which has been shown to be a reliable and sensitive method for detecting early-stage skin cancer and reducing the number of unnecessary excisions. Patients at high risk of developing melanoma require long-term surveillance. Use of digital dermoscopy follow-up of these patients has led to improved outcomes. Combined follow-up programmes using total-body photography and digital dermoscopy have led to further improvements in early diagnosis and diagnostic accuracy. Dermoscopy is now widely used by dermatologists, but the public health impact of this tool is yet to be evaluated. Despite the clear advantages of dermoscopy and digital follow-up meth-ods, dermoscopy training and access to digital dermoscopy among dermatologists and general practitioners needs to be improved.

Transcranial Doppler ultrasound in the diagnosis of brain death. Is it useful or does it delay the diagnosis?

PubMed

Escudero, D; Otero, J; Quindós, B; Viña, L

2015-05-01

Transcranial Doppler ultrasound is able to demonstrate cerebral circulatory arrest associated to brain death, being especially useful in sedated patients, or in those in which complete neurological exploration is not possible. Transcranial Doppler ulstrasound is a portable, noninvasive and high-availability technique. Among its limitations, mention must be made of the absence of acoustic windows and false-negative cases. In patients clinically diagnosed with brain death, with open skulls or with anoxia as the cause of death, cerebral blood flow can be observed by ultrasound, since cerebral circulatory arrest is not always synchronized to the clinical diagnosis. The diagnostic rate is therefore time-dependent, and this fact that must be recognized in order to avoid delays in death certification. Despite its limitations, transcranial Doppler ulstrasound helps solve common diagnostic problems, avoids the unnecessary consumption of resources, and can optimize organ harvesting for transplantation. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

SYN-PEDS: SYNtactical Pediatric Evaluation and Diagnostic System

PubMed Central

Witten, Matthew; Maloney, David

1980-01-01

SYN-PEDS is a multimodular system which is designed to be an inhome interactive access to a neonatal and pediatric diagnostic information database. This system is designed to assist a parent in assessing his child's condition, as well as in determining whether or not the child needs immediate medical attention. This system is not designed to replace the pediatrician but rather, it is designed as a preventative and health maintenance information system which has the unusually nice side benefit if helping to reduce medical system costs by cutting down on the number of unnecessary visits to private and local clinics as well as private physicians. The current version of SYN-PEDS is composed of of four operative modules: CRITICAL, TREAT, CLINFO, and DIAGNOSE/SYMPTM. These four modules allow the parent/user to interact with the SYN-PEDS system in various modes. As an example, CLINFO is the module which provides clinical information on a variety of subjects. This module is for a parent who wishes information on a particular subject of interest.

One or two serological assay testing strategy for diagnosis of HBV and HCV infection? The use of predictive modelling.

PubMed

Parry, John V; Easterbrook, Philippa; Sands, Anita R

2017-11-01

Initial serological testing for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is conducted using either rapid diagnostic tests (RDT) or laboratory-based enzyme immunoassays (EIA)s for detection of hepatitis B surface antigen (HBsAg) or antibodies to HCV (anti-HCV), typically on serum or plasma specimens and, for certain RDTs, capillary whole blood. WHO recommends the use of standardized testing strategies - defined as a sequence of one or more assays to maximize testing accuracy while simplifying the testing process and ideally minimizing cost. Our objective was to examine the diagnostic outcomes of a one- versus two-assay serological testing strategy. These data were used to inform recommendations in the 2017 WHO Guidelines on hepatitis B and C testing. Few published studies have compared diagnostic outcomes for one-assay versus two-assay serological testing strategies for HBsAg and anti-HCV. Therefore, the principles of Bayesian statistics were used to conduct a modelling exercise to examine the outcomes of a one-assay versus two-assay testing strategy when applied to a hypothetical population of 10,000 individuals. The resulting model examined the diagnostic outcomes (true and false positive diagnoses; true and false negative diagnoses; positive and negative predictive values as a function of prevalence; and total tests required) for both one-assay and two-assay testing strategies. The performance characteristics assumed for assays used within the testing strategies were informed by WHO prequalification assessment findings and systematic reviews for diagnostic accuracy studies. Each of the presumptive testing strategies (one-assay or two-assay) was modelled at varying prevalences of HBsAg (10%, 2% and 0.4%) and of anti-HCV (40%, 10%, 2% and 0.4%), aimed at representing the range of testing populations typically encountered in WHO Member States. When the two-assay testing strategy was considered, the model assumed the independence of the two assays. Modeling demonstrated that applying a single assay (HBsAg or anti-HCV), even with high specificity (99%), may result in considerable numbers of false positive diagnoses and low positive predictive values (PPV), particularly in lower prevalence settings. Even at very low prevalences shifting to a two-assay testing strategy would result in a PPV approaching 1.0. When test sensitivity is high (>99%) false negative reactions are rare at all but the highest prevalences; but a two-test strategy might yield more false negative diagnoses. The order in which the tests are used has no impact on the overall accuracy of a two-assay strategy though it may impact the total number of tests needed to complete the diagnostic strategy, incurring added cost and complexity. HBsAg assays may have a low sensitivity (<90%), and result in large numbers of false negative diagnoses, particularly in high prevalence settings, which would be exacerbated in the two-assay testing strategy. In contrast, most anti-HCV assays have high sensitivity and lead to fewer false negative results, both in the one-assay and two-assay testing strategies. At prevalences ≤2% the number of tests needed using a second assay was nearly always small, at <300 per 10,000 individuals tested, making sustainability of a second assay uncertain in such a setting. A key public health objective of an effective testing strategy is to identify all individuals who would benefit from treatment. Therefore, a strategy that prioritizes a high NPV (minimal false negatives) may be acceptable even if the PPV is suboptimal (some false positives) as the implementation of such a public health programme must also take account of other factors such as costs, feasibility, impact on testing uptake and linkage to care, and consequences of a false-positive test. This rationale informed the development of the WHO Viral Hepatitis Testing Guidelines, with a conditional recommendation for a one-assay serological testing strategy in most testing settings and populations (≥0.4% prevalence in population tested). A one-test strategy results in few failures to diagnose infection and, although it is associated under most assumptions with a sub-optimal PPV, benefits include greater simplicity, easier implementation, lower costs and better feasibility, uptake and linkage to care. Furthermore, prior to antiviral therapy all those diagnosed either HBsAg or anti-HCV positive will require confirmation of viræmia, preventing unnecessary treatment of those who may be false positive on serology. For HBsAg, in low-prevalence settings (≤0.4%), a second recommendation was made to consider a two-assay testing strategy, using a confirmatory neutralization step or a second different HBsAg assay.

Revolutionizing clinical microbiology laboratory organization in hospitals with in situ point-of-care.

PubMed

Cohen-Bacrie, Stéphan; Ninove, Laetitia; Nougairède, Antoine; Charrel, Rémi; Richet, Hervé; Minodier, Philippe; Badiaga, Sékéné; Noël, Guilhem; La Scola, Bernard; de Lamballerie, Xavier; Drancourt, Michel; Raoult, Didier

2011-01-01

Clinical microbiology may direct decisions regarding hospitalization, isolation and anti-infective therapy, but it is not effective at the time of early care. Point-of-care (POC) tests have been developed for this purpose. One pilot POC-lab was located close to the core laboratory and emergency ward to test the proof of concept. A second POC-lab was located inside the emergency ward of a distant hospital without a microbiology laboratory. Twenty-three molecular and immuno-detection tests, which were technically undemanding, were progressively implemented, with results obtained in less than four hours. From 2008 to 2010, 51,179 tests yielded 6,244 diagnoses. The second POC-lab detected contagious pathogens in 982 patients who benefited from targeted isolation measures, including those undertaken during the influenza outbreak. POC tests prevented unnecessary treatment of patients with non-streptococcal tonsillitis (n = 1,844) and pregnant women negative for Streptococcus agalactiae carriage (n = 763). The cerebrospinal fluid culture remained sterile in 50% of the 49 patients with bacterial meningitis, therefore antibiotic treatment was guided by the molecular tests performed in the POC-labs. With regard to enterovirus meningitis, the mean length-of-stay of infected patients over 15 years old significantly decreased from 2008 to 2010 compared with 2005 when the POC was not in place (1.43±1.09 versus 2.91±2.31 days; p = 0.0009). Altogether, patients who received POC tests were immediately discharged nearly thrice as often as patients who underwent a conventional diagnostic procedure. The on-site POC-lab met physicians' needs and influenced the management of 8% of the patients that presented to emergency wards. This strategy might represent a major evolution of decision-making regarding the management of infectious diseases and patient care.

The predictive value of specific immunoglobulin E levels in serum for the outcome of the development of tolerance in cow's milk allergy.

PubMed

Martorell, A; García Ara, M C; Plaza, A M; Boné, J; Nevot, S; Echeverria, L; Alonso, E; Garde, J

2008-01-01

Immunoglobulin E-mediated allergy to cow's milk protein (CMP) tends to subside over years of follow-up. The gold standard for detecting such allergy has been the oral challenge test. The development of some other test for determining the correct timing of the oral challenge test would avoid unnecessary patient discomfort. The aim of this study was to determine whether monitoring cow's milk (CM) specific IgE levels over time can be used as a predictor for determining when patients develop clinical tolerance. A prospective 4-year follow-up study was made of 170 patients with IgE-mediated allergy to CMP, involving periodic evaluations (12, 18, 24, 36 and 48 months) with the determination of casein and CM specific IgE on each visit, along with CM challenge testing. ROC curves were used to analyse the sensitivity, specificity and predictive values of the casein and CM specific IgE levels versus the challenge test outcomes at the different moments of follow-up. In the course of follow-up, 140 infants (82 %) became tolerant. Specific IgE levels to CM: 2.58, 2.5, 2.7, 2.26, 5 kU(A)/l and to casein: 0.97, 1.22, 3, 2.39, 2.73 kU(A)/l, respectively, predicted clinical reactivity (greatest diagnostic efficiency values) at the different analysed moments of follow-up (12, 18, 24, 36 and 48 months). Quantification of CMP specific IgE is a useful test for diagnosing symptomatic allergy to CM in the paediatric population, and could eliminate the need to perform oral challenges tests in a significant number of children.

Cost-effectiveness of anatomical and functional test strategies for stable chest pain: public health perspective from a middle-income country.

PubMed

Bertoldi, Eduardo G; Stella, Steffen F; Rohde, Luis Eduardo P; Polanczyk, Carisi A

2017-05-04

The aim of this research is to evaluate the relative cost-effectiveness of functional and anatomical strategies for diagnosing stable coronary artery disease (CAD), using exercise (Ex)-ECG, stress echocardiogram (ECHO), single-photon emission CT (SPECT), coronary CT angiography (CTA) or stress cardiacmagnetic resonance (C-MRI). Decision-analytical model, comparing strategies of sequential tests for evaluating patients with possible stable angina in low, intermediate and high pretest probability of CAD, from the perspective of a developing nation's public healthcare system. Hypothetical cohort of patients with pretest probability of CAD between 20% and 70%. The primary outcome is cost per correct diagnosis of CAD. Proportion of false-positive or false-negative tests and number of unnecessary tests performed were also evaluated. Strategies using Ex-ECG as initial test were the least costly alternatives but generated more frequent false-positive initial tests and false-negative final diagnosis. Strategies based on CTA or ECHO as initial test were the most attractive and resulted in similar cost-effectiveness ratios (I$ 286 and I$ 305 per correct diagnosis, respectively). A strategy based on C-MRI was highly effective for diagnosing stable CAD, but its high cost resulted in unfavourable incremental cost-effectiveness (ICER) in moderate-risk and high-risk scenarios. Non-invasive strategies based on SPECT have been dominated. An anatomical diagnostic strategy based on CTA is a cost-effective option for CAD diagnosis. Functional strategies performed equally well when based on ECHO. C-MRI yielded acceptable ICER only at low pretest probability, and SPECT was not cost-effective in our analysis. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Anesthesiologists' and surgeons' perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians' decisions to order pre-operative tests.

PubMed

Patey, Andrea M; Islam, Rafat; Francis, Jill J; Bryson, Gregory L; Grimshaw, Jeremy M

2012-06-09

Routine pre-operative tests for anesthesia management are often ordered by both anesthesiologists and surgeons for healthy patients undergoing low-risk surgery. The Theoretical Domains Framework (TDF) was developed to investigate determinants of behaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists' and surgeons' perceptions of ordering routine tests for healthy patients undergoing low-risk surgery. Sixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Content analysis of physicians' statements into the relevant theoretical domains was performed. Specific beliefs were identified by grouping similar utterances of the interview participants. Relevant domains were identified by noting the frequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence on the performance of the behaviour under investigation. Seven of the twelve domains were identified as likely relevant to changing clinicians' behaviour about pre-operative test ordering for anesthesia management. Key beliefs were identified within these domains including: conflicting comments about who was responsible for the test-ordering (Social/professional role and identity); inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences); and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources). Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences). There were also conflicting comments about the potential consequences associated with reducing testing, from negative (delay or cancel patients' surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs about consequences). Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation). We identified key factors that anesthesiologists and surgeons believe influence whether they order pre-operative tests routinely for anesthesia management for a healthy adults undergoing low-risk surgery. These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.

Alternative approaches for vertebrate ecotoxicity tests in the 21st century: A review of developments over the last 2 decades and current status

EPA Science Inventory

The need for alternative approaches to the use of vertebrate animals for hazard assessing chemicals and pollutants has become of increasing importance. It is now the first consideration when initiating a vertebrate ecotoxicity test, to ensure that unnecessary use of vertebrate or...

Small-Sample Equating with Prior Information. Research Report. ETS RR-09-25

ERIC Educational Resources Information Center

Livingston, Samuel A.; Lewis, Charles

2009-01-01

This report proposes an empirical Bayes approach to the problem of equating scores on test forms taken by very small numbers of test takers. The equated score is estimated separately at each score point, making it unnecessary to model either the score distribution or the equating transformation. Prior information comes from equatings of other…

Ensuring Success of Adaptive Control Research Through Project Lifecycle Risk Mitigation

NASA Technical Reports Server (NTRS)

Pavlock, Kate M.

2011-01-01

Lessons Learne: 1. Design-out unnecessary risk to prevent excessive mitigation management during flight. 2. Consider iterative checkouts to confirm or improve human factor characteristics. 3. Consider the total flight test profile to uncover unanticipated human-algorithm interactions. 4. Consider test card cadence as a metric to assess test readiness. 5. Full-scale flight test is critical to development, maturation, and acceptance of adaptive control laws for operational use.

The contemporary spectrum of multiple sclerosis misdiagnosis: A multicenter study.

PubMed

Solomon, Andrew J; Bourdette, Dennis N; Cross, Anne H; Applebee, Angela; Skidd, Philip M; Howard, Diantha B; Spain, Rebecca I; Cameron, Michelle H; Kim, Edward; Mass, Michele K; Yadav, Vijayshree; Whitham, Ruth H; Longbrake, Erin E; Naismith, Robert T; Wu, Gregory F; Parks, Becky J; Wingerchuk, Dean M; Rabin, Brian L; Toledano, Michel; Tobin, W Oliver; Kantarci, Orhun H; Carter, Jonathan L; Keegan, B Mark; Weinshenker, Brian G

2016-09-27

To characterize patients misdiagnosed with multiple sclerosis (MS). Neurologists at 4 academic MS centers submitted data on patients determined to have been misdiagnosed with MS. Of 110 misdiagnosed patients, 51 (46%) were classified as "definite" and 59 (54%) "probable" misdiagnoses according to study definitions. Alternate diagnoses included migraine alone or in combination with other diagnoses 24 (22%), fibromyalgia 16 (15%), nonspecific or nonlocalizing neurologic symptoms with abnormal MRI 13 (12%), conversion or psychogenic disorders 12 (11%), and neuromyelitis optica spectrum disorder 7 (6%). Duration of misdiagnosis was 10 years or longer in 36 (33%) and an earlier opportunity to make a correct diagnosis was identified for 79 patients (72%). Seventy-seven (70%) received disease-modifying therapy and 34 (31%) experienced unnecessary morbidity because of misdiagnosis. Four (4%) participated in a research study of an MS therapy. Leading factors contributing to misdiagnosis were consideration of symptoms atypical for demyelinating disease, lack of corroborative objective evidence of a CNS lesion as satisfying criteria for MS attacks, and overreliance on MRI abnormalities in patients with nonspecific neurologic symptoms. Misdiagnosis of MS leads to unnecessary and potentially harmful risks to patients. Misinterpretation and misapplication of MS clinical and radiographic diagnostic criteria are important contemporary contributors to misdiagnosis. © 2016 American Academy of Neurology.

Pilot of integrated, colocated neurology in a primary care medical home.

PubMed

Young, Nathan P; Elrashidi, Muhamad Y; Crane, Sarah J; Ebbert, Jon O

2017-06-01

Novel health care delivery models are needed to reduce health care use while delivering effective and safe care. We developed a model of a neurologist integrated and colocated in primary care leveraging "curbside," electronic, and traditional consultations. Our objective was to examine the impact on health care resource use of diagnostic testing and referrals for face-to-face neurological consultation and adverse outcomes associated with electronic and curbside consultations. Consecutive patients from December 1, 2014, to March 13, 2015, were included in the analysis about whom contact was made between a primary care clinician and a colocated neurologist. Over 3.5 months of the pilot, 359 unique patients generated 429 consultations (179 curbsides, 68 electronic consultations, and 182 face-to-face visits). The integrated model resulted in avoidance of 78 face-to-face tertiary neurology consultations, 39 brain magnetic resonance imaging, 50 electromyograms, and 53 other advanced imaging studies. Earlier curbside consultation may have prevented unnecessary testing or face-to-face tertiary neurology consultations in 40 (22%) patients. Earlier face-to-face consultation may have avoided expensive testing in 31 (17%) patients. No cases met criteria for an adverse outcome. The number of referrals to tertiary neurology declined by 64%, and the total number of face-to-face visits per month declined by 25%. Colocated neurology in a primary care medical home offers a promising intervention to deliver high-value care. © 2016 John Wiley & Sons, Ltd.

Unnecessary surgery.

PubMed Central

Leape, L L

1989-01-01

The extent of unnecessary surgery has been the object of considerable speculation and occasional wild accusation in recent years. Most evidence of the existence of unnecessary surgery, such as information from studies of geographic variations and the results of second surgical opinion programs, is circumstantial. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent. Most unnecessary surgery results from physician uncertainty about the effectiveness of an operation. Elimination of this uncertainty requires more efficient production and dissemination of scientific information about clinical effectiveness. In the absence of adequate data from scientific studies, the use of a consensus of expert opinion, disseminated by means of comprehensive practice guidelines, offers the best opportunity to identify and eliminate unnecessary surgery. PMID:2668237

Empirical validation of guidelines for the management of pharyngitis in children and adults.

PubMed

McIsaac, Warren J; Kellner, James D; Aufricht, Peggy; Vanjaka, Anita; Low, Donald E

2004-04-07

Recent guidelines for management of pharyngitis vary in their recommendations concerning empirical antibiotic treatment and the need for laboratory confirmation of group A streptococcus (GAS). To assess the impact of guideline recommendations and alternative approaches on identification and treatment of GAS pharyngitis in children and adults. Throat cultures and rapid antigen tests were performed on 787 children and adults aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002. Recommendations from 2 guidelines (those of the Infectious Diseases Society of America and of the American College of Physicians-American Society of Internal Medicine/American Academy of Family Physicians/US Centers for Disease Control and Prevention) were compared with rapid testing alone, a clinical prediction rule (ie, the modified Centor score), and a criterion standard of treatment for positive throat culture results only. Sensitivity and specificity of each strategy for identifying GAS pharyngitis, total antibiotics recommended, and unnecessary antibiotic prescriptions. In children, sensitivity for streptococcal infection ranged from 85.8% (133/155; 95% confidence interval [CI], 79.3%-90.0%) for rapid testing to 100% for culturing all. In adults, sensitivity ranged from 76.7% (56/73; 95% CI, 65.4%-85.8%) for rapid testing without culture confirmation of negative results to 100% for culturing all. In children, specificity ranged from 90.3% (270/299; 95% CI, 86.4%-93.4%) for use of modified Centor score and throat culture to 100% for culturing all. In adults, specificity ranged from 43.8% (114/260; 95% CI, 37.7%-50.1%) for empirical treatment based on a modified Centor score of 3 or 4 to 100% for culturing all. Total antibiotic prescriptions were lowest with rapid testing (24.7% [194/787]; 95% CI, 21.7%-27.8%) and highest with empirical treatment of high-risk adults (45.7% [360/787]; 95% CI, 42.2%-49.3%), due to a high rate of unnecessary prescriptions in adults (43.8% [146/333]; 95% CI, 38.4%-49.4%). Guideline recommendations for the selective use of throat cultures but antibiotic treatment based only on positive rapid test or throat culture results can reduce unnecessary use of antibiotics for treatment of pharyngitis. However, empirical treatment of adults having a Centor score of 3 or 4 is associated with a high rate of unnecessary antibiotic use. In children, strategies incorporating throat culture or throat culture confirmation of negative rapid antigen test results are highly sensitive and specific. Throat culture of all adults or those selected on the basis of a clinical prediction rule had the highest sensitivity and specificity.

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives

PubMed Central

Litchfield, Ian; Bentham, Louise; Hill, Ann; McManus, Richard J; Lilford, Richard; Greenfield, Sheila

2015-01-01

Background The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. Methods We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. Results A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. Conclusions A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions. PMID:26251507

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

PubMed

Litchfield, Ian; Bentham, Louise; Hill, Ann; McManus, Richard J; Lilford, Richard; Greenfield, Sheila

2015-11-01

The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

SERIAL PERCENT-FREE PSA IN COMBINATION WITH PSA FOR POPULATION-BASED EARLY DETECTION OF PROSTATE CANCER

PubMed Central

Ankerst, Donna Pauler; Gelfond, Jonathan; Goros, Martin; Herrera, Jesus; Strobl, Andreas; Thompson, Ian M.; Hernandez, Javier; Leach, Robin J.

2016-01-01

PURPOSE To characterize the diagnostic properties of serial percent-free prostate-specific antigen (PSA) in relation to PSA in a multi-ethnic, multi-racial cohort of healthy men. MATERIALS AND METHODS 6,982 percent-free PSA and PSA measures were obtained from participants in a 12 year+ Texas screening study comprising 1625 men who never underwent biopsy, 497 who underwent one or more biopsies negative for prostate cancer, and 61 diagnosed with prostate cancer. Area underneath the receiver-operating-characteristic-curve (AUC) for percent-free PSA, and the proportion of patients with fluctuating values across multiple visits were determined according to two thresholds (under 15% versus 25%) were evaluated. The proportion of cancer cases where percent-free PSA indicated a positive test before PSA > 4 ng/mL did and the number of negative biopsies that would have been spared by percent-free PSA testing negative were computed. RESULTS Percent-free PSA fluctuated around its threshold of < 25% (< 15%) in 38.3% (78.1%), 42.2% (20.9%), and 11.4% (25.7%) of patients never biopsied, with negative and positive biopsies, respectively. At the same thresholds, percent-free PSA tested positive earlier than PSA in 71.4% (34.2%) of cancer cases, and among men with multiple negative biopsies and a PSA > 4 ng/mL, percent-free PSA would have tested negative in 31.6% (65.8%) instances. CONCLUSIONS Percent-free PSA should accompany PSA testing in order to potentially spare unnecessary biopsies or detect cancer earlier. When near the threshold, both tests should be repeated due to commonly observed fluctuation. PMID:26979652

Ectopic ACTH and CRH co-secreting tumor localized by 68Ga-DOTA-TATE PET/CT

PubMed Central

Papadakis, Georgios Z.; Bagci, Ulas; Sadowski, Samira M.; Patronas, Nicholas J.; Stratakis, Constantine A.

2015-01-01

Diagnosis of ectopic adrenocorticotropic hormone (ACTH) and corticotropin releasing hormone (CRH) co-secreting tumors causing Cushing syndrome (CS) is challenging, since these tumors are rare and their diagnosis is frequently confused with Cushing disease (CD), due to the effect of CRH on the pituitary. We report a case of a 21-year-old male who was referred to our institution with persistent hypercortisolemia and CS after undergoing unnecessary transsphenoidal surgery (TSS). 68Ga-DOTA-TATE PET/CT revealed increased tracer uptake in the thymus which was histologically proved to be neuroendocrine tumor (NET) staining positive for ACTH and CRH. Imaging with 18F-FDG PET/CT was not diagnostic. PMID:26018709

[DIFFERENTIATED TACTICS OF VIDEOTHORACOSCOPIC DIAGNOSIS OF THE PLEURAL EXUDATE SYNDROME].

PubMed

Ivashchenko, V E; Kalabukha, I A; Mayetnyi, E M

2016-04-01

Differentiated tactics of diagnostic videothoracoscopy (VTHS) in a pleural exudate syndrome, which ought to be treated with hydrothorax elimination and artificial pneumothorax creation, was proposed. Further roentgenological investigation permits to create a plan for the operation conduction and a certain anesthesia application. Criteria for the operation planning and the anesthesiological support choice were elaborated. Results of VTHS conduction in 261 patients in Department of Thoracic Surgery were analyzed. The differentiated tactics for the VTHS performance application have had saved the patients from the unnecessary endotracheal narcosis conduction, and reduced a pharmacological load on a patient, as well as a rate of contraindications for the operation usage and the stationary treatment duration.

The role of radionuclide imaging in the triage of patients with chest pain in the emergency department.

PubMed

Abbott, B G; Wackers, F J

2000-02-01

The triage of patients presenting to the emergency department with chest pain and a normal or nondiagnostic ECG poses a significant diagnostic challenge to emergency physicians and cardiologists, leading to unnecessary hospital admissions and substantial associated costs. Radionuclide myocardial perfusion imaging can potentially play an important role in this setting, by providing both a safe and efficient means to risk stratify patients with a low-to-moderate likelihood of unstable angina. The proposed algorithm may serve as a strategy to improve utilization of hospital resources while safely identifying the subgroup of patients with acute chest discomfort who do not need to be admitted to the hospital.

Unusual Metastasis of Medullary Thyroid Carcinoma to the Breast: A Cytological and Histopathological Correlation

PubMed Central

Tanwar, Parul; Gandhi, Jatin S; Sharma, Anila; Gupta, Manoj; Choudhary, Partha S

2018-01-01

Breast metastases are a relatively rare condition and account for approximately 0.5–2% of all breast tumors. Recognition of metastatic tumors in the breast is important because it would prevent unnecessary mutilating surgery and would lead to appropriate treatment of the primary tumor. Breast metastases from medullary thyroid cancer (MTC) are very rare with only 21 reported cases in the literature. Some MTCs mimic primary invasive lobular carcinoma of the breast histopathologically and radiologically, making the distinction between the two diagnostically challenging. We present the case of a 45-year-old female presenting with a lump breast, which was later found out to be metastasis from medullary carcinoma thyroid. PMID:29643661

Contacts with out-of-hours primary care for nonurgent problems: patients' beliefs or deficiencies in healthcare?

PubMed

Keizer, Ellen; Smits, Marleen; Peters, Yvonne; Huibers, Linda; Giesen, Paul; Wensing, Michel

2015-10-28

In the Netherlands, about half of the patient contacts with a general practitioner (GP) cooperative are nonurgent from a medical perspective. A part of these problems can wait until office hours or can be managed by the patient himself without further professional care. However, from the patient's perspective, there may be a need to contact a physician immediately. Our objective was to determine whether contacts with out-of-hours primary care made by patients with nonurgent problems are the result of patients' beliefs or of deficiencies in the healthcare system. We performed a survey among 2000 patients with nonurgent health problems in four GP cooperatives in the Netherlands. Two GPs independently judged the medical necessity of the contacts of all patients in this study. We examined characteristics, views and motives of patients with medically necessary contacts and those without medically necessary contacts. Descriptive statistics were used to describe the characteristics, views and reasons of the patients with medically unnecessary contacts and medically necessary contacts. Differences between these groups were tested with chi-square tests. The response rate was 32.3 % (N = 646). Of the nonurgent contacts 30.4 % were judged as medically necessary (95 % CI 27.0-34.2). Compared to patients with nonurgent but medically necessary contacts, patients with medically unnecessary contacts were younger and were more often frequent attenders. They had longer-existing problems, lower self-assessed urgency, and more often believed GP cooperatives are intended for all help requests. Worry was the most frequently mentioned motive for contacting a GP cooperative for patients with a medically unnecessary contact (45.3 %) and a perceived need to see a GP for patients with a medically necessary contact (44.2 %). Perceived availability (5.8 %) and accessibility (8.3 %) of a patient's own GP played a role for some patients. Motives for contacting a GP cooperative are mostly patient-related, but also deficiencies in access to general practice may partly explain medically unnecessary use. Efforts to change the use of GP cooperatives should focus on education of subgroups with an increased likelihood of contact for medically unnecessary problems. Improvement of access to daytime primary care may also decrease use of the GP cooperative.

THE ROLE OF LAPAROSCOPY IN BLUNT ABDOMINAL TRAUMA: DIAGNOSTIC, THERAPEUTIC OR BOTH?

PubMed

Koto, M Z; Mosai, F; Matsevych, O Y

2017-06-01

The use of laparoscopy in blunt abdominal trauma is gaining popularity as a useful diagnostic tool to avoid unnecessary laparotomies where there is diagnostic dilemma. But the feasibility of using laparoscopy for therapeutic intervention in these patients has been debated. Even though recent case reports seem to suggest that these patients can be managed using laparoscopy, the practice is not yet wildly adopted. A retrospective analysis of a prospectively collected data was done. All adult patients who presented with abdominal trauma and were offered laparoscopic surgery at Dr George Mukhari Academic Hospital (DGMAH) from 2012 to 2015 were reviewed. Data was retrieved from our departmental database and analysed using descriptive statistics. A total of 318 patients were reviewed and 35 patients had blunt abdominal trauma and were included in the study. All the patients were offered laparoscopy. The median age was 30, with 91% of our patients males. The highest injury severity score calculated was 38. At least 77% of the patients were managed using laparoscopy. This includes 43% who had both diagnostic and therapeutic intervention and 34% who had only diagnostic laparoscopy. Eight patients were converted to open surgery mainly due to active bleeding and complex injuries. We did not have any non-therapeutic laparotomies. There was no documented procedure‑related morbidity and mortality. The positive outcomes seen from the study suggest that laparoscopy can be safe and feasible in both diagnostic and therapeutic interventions in carefully selected blunt abdominal trauma patients. A conversion to open surgery should not be regarded as a failure but rather as a sign of mature and sound clinical judgement acknowledging the limitations of laparoscopy and/or the surgeon.

THE ROLE OF LAPAROSCOPY IN BLUNT ABDOMINAL TRAUMA: DIAGNOSTIC, THERAPEUTIC OR BOTH?

PubMed

Mosai, F

2017-09-01

The use of laparoscopy in blunt abdominal trauma is gaining popularity as a useful diagnostic tool to avoid unnecessary laparotomies where there is diagnostic dilemma. But the feasibility of using laparoscopy for therapeutic intervention in these patients has been debated. Even though recent case reports seem to suggest that these patients can be managed using laparoscopy, the practice is not yet wildly adopted. A retrospective analysis of a prospectively collected data was done. All adult patients who presented with abdominal trauma and were offered laparoscopic surgery at DGMAH from 2012 to 2015 were reviewed. Data was retrieved from our departmental database and analysed using descriptive statistics. A total of 318 patients were reviewed and 35 patients had blunt abdominal trauma and were included in the study. All the patients were offered laparoscopy. The median age was 30, with 91% of our patients being males. The highest injury severity score calculated was 38. At least 77% of the patients were managed using laparoscopy. This includes 43% who had both diagnostic and therapeutic intervention and 34% had only diagnostic laparoscopy. Eight patients were converted to open surgery mainly due to active bleeding and complex injuries. We did not have any non-therapeutic laparotomies, with no documented procedure related morbidity and mortality. The positive outcomes seen from the study suggest that laparoscopy can be safe and feasible in both diagnostic and therapeutic interventions in carefully selected blunt abdominal trauma patients. A conversion to open surgery should not be regarded as a failure but rather as a sign of mature and sound clinical judgement acknowledging the limitations of laparoscopy and/or the surgeon.

In-office diagnostic arthroscopy for knee and shoulder intra-articular injuries its potential impact on cost savings in the United States

PubMed Central

2014-01-01

Background The purpose of this analysis was to determine whether in office diagnostic needle arthroscopy (Visionscope Imaging System [VSI]) can provide for improved diagnostic assessment and; more cost effective care. Methods Data on arthroscopy procedures in the US for deep seated pathology in the knee and shoulder were used (Calendar Year 2012). These procedures represent approximately 25-30% of all arthroscopic procedures performed annually. Sensitivities, specificities, positive predictive, and negative predictive values for MRI analysis of this deep seated pathology from systematic reviews and meta-analyses were used in assessing for false positive and false negative MRI findings. The costs of performing diagnostic and surgical arthroscopy procedures (using 2013 Medicare reimbursement amounts); costs associated with false negative findings; and the costs for treating associated complications arising from diagnostic and therapeutic arthroscopy procedures were then assessed. Results In patients presenting with medial meniscal pathology (ICD9CM diagnosis 836.0 over 540,000 procedures in CY 2012); use of the VSI system in place of MRI assessment (standard of care) resulted in a net cost savings to the system of $151 million. In patients presenting with rotator cuff pathology (ICD9CM 840.4 over 165,000 procedures in CY2012); use of VSI in place of MRI similarly saved $59 million. These savings were realized along with more appropriate care as; fewer patients were exposed to higher risk surgical arthroscopic procedures. Conclusions The use of an in-office arthroscopy system can: possibly save the US healthcare system money; shorten the diagnostic odyssey for patients; potentially better prepare clinicians for arthroscopic surgery (when needed) and; eliminate unnecessary outpatient arthroscopy procedures, which commonly result in surgical intervention. PMID:24885678

Novel Indocyanine Green-Phytate Colloid Technique for Sentinel Node Detection in Head and Neck: Mouse Study.

PubMed

Araki, Koji; Mizokami, Daisuke; Tomifuji, Masayuki; Yamashita, Taku; Ohnuki, Kazunobu; Umeda, Izumi O; Fujii, Hirofumi; Kosuda, Shigeru; Shiotani, Akihiro

2014-08-01

Sentinel node navigation surgery using real-time, near-infrared imaging with indocyanine green is becoming popular by allowing head and neck surgeons to avoid unnecessary neck dissection. The major drawback of this method is its quick migration through the lymphatics, limiting the diagnostic time window and undesirable detection of downstream nodes. We resolved this problem by mixing indocyanine green (ICG) with phytate colloid to retard its migration and demonstrated its feasibility in a nude mouse study. Experimental prospective animal study. Animal laboratory. Indocyanine green at 3 concentrations was tested to determine the optimal concentration for sentinel lymph node detection in a mouse model. Effect of indocyanine green with phytate colloid mixture solutions was also analyzed. Indocyanine green or mixture solution at different mixing ratios were injected into the tongue of nude mice and near-infrared fluorescence images were captured sequentially for up to 48 hours. The brightness of fluorescence in the sentinel lymph node and lymph nodes further downstream were assessed. Indocyanine green concentration >50 μg/mL did not improve sentinel lymph node detection. The addition of phytate colloid to indocyanine green extended the period when sentinel lymph node was detectable. Second echelon lymph nodes were not imaged in mice injected with the mixture, while these were visualized in mice injected with indocyanine green alone. This novel technique of ICG-phytate colloid mixture allows prolonged diagnostic time window, prevention of downstream subsequent nodes detection, and improved accuracy for the detection of true sentinel lymph nodes. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.

Responses to Bacteria, Virus, and Malaria Distinguish the Etiology of Pediatric Clinical Pneumonia

PubMed Central

Valim, Clarissa; Ahmad, Rushdy; Lanaspa, Miguel; Tan, Yan; Acácio, Sozinho; Gillette, Michael A.; Almendinger, Katherine D.; Milner, Danny A.; Madrid, Lola; Pellé, Karell; Harezlak, Jaroslaw; Silterra, Jacob; Alonso, Pedro L.; Carr, Steven A.; Mesirov, Jill P.; Wiegand, Roger C.; Bassat, Quique

2016-01-01

Rationale: Plasma-detectable biomarkers that rapidly and accurately diagnose bacterial infections in children with suspected pneumonia could reduce the morbidity of respiratory disease and decrease the unnecessary use of antibiotic therapy. Objectives: Using 56 markers measured in a multiplexed immunoassay, we sought to identify proteins and protein combinations that could discriminate bacterial from viral or malarial diagnoses. Methods: We selected 80 patients with clinically diagnosed pneumonia (as defined by the World Health Organization) who also met criteria for bacterial, viral, or malarial infection based on clinical, radiographic, and laboratory results. Ten healthy community control subjects were enrolled to assess marker reliability. Patients were subdivided into two sets: one for identifying potential markers and another for validating them. Measurements and Main Results: Three proteins (haptoglobin, tumor necrosis factor receptor 2 or IL-10, and tissue inhibitor of metalloproteinases 1) were identified that, when combined through a classification tree signature, accurately classified patients into bacterial, malarial, and viral etiologies and misclassified only one patient with bacterial pneumonia from the validation set. The overall sensitivity and specificity of this signature for the bacterial diagnosis were 96 and 86%, respectively. Alternative combinations of markers with comparable accuracy were selected by support vector machine and regression models and included haptoglobin, IL-10, and creatine kinase–MB. Conclusions: Combinations of plasma proteins accurately identified children with a respiratory syndrome who were likely to have bacterial infections and who would benefit from antibiotic therapy. When used in conjunction with malaria diagnostic tests, they may improve diagnostic specificity and simplify treatment decisions for clinicians. PMID:26469764

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bourne, H.G. Jr.; Wynd, J.C.; Dwork, R.E.

Measures in use or being considered by the Ohio Dept. of Health to reduce radiation hazards, particularly from fallout radionuclides and from excessive medical and dental diagnostic exposure, are discussed. The extent of contamination of Ohio milk with radiostrontium, cesium, and iodine has been a source of apprehension. however, more important in attempts to halt the upward trend in exposure to radiation is reduction of exposure in radiodiagnosis. The individual physician or dentist is the appropriate responsible agent who must weigh benefit against nisk, and this right of the physician or dentist is guaranteed in the statutes whlch do notmore » limit the kind and amount of radiation that may be intentionally applied to a person for diagnostic or therapeutic purposes by or under the direction of a physician or dentist. To fulfill this responsibility the following precepts are recommended: There should be clear-cut clinical indications before any x-ray examination is undertaken, and it should be ascertained whether there has been a previous radiological examination which would make further examination unnecessary. There should be consultation between clinician and radiologist before extensive or repeated radiological examinations of young individuals are undertaken. To reduce repeat studies, strict attention should be paid to adequate preparation before abdominal investigation. Special precautions should be adopted in radiography of pregnant women. Previous history of radiotherapy should be ascertained before a new course of treatment is undertaken. Radiotherapy should not be employed in benign conditions which respond to other types of treatment. Specific ways of reducing exposure during radiologic and fluoroscopic tests are also considered. (BBB)« less

An Evaluation of Factors Associated With Pathogenic PRSS1, SPINK1, CTFR, and/or CTRC Genetic Variants in Patients With Idiopathic Pancreatitis.

PubMed

Jalaly, Niloofar Y; Moran, Robert A; Fargahi, Farshid; Khashab, Mouen A; Kamal, Ayesha; Lennon, Anne Marie; Walsh, Christi; Makary, Martin A; Whitcomb, David C; Yadav, Dhiraj; Cebotaru, Liudmila; Singh, Vikesh K

2017-08-01

We evaluated factors associated with pathogenic genetic variants in patients with idiopathic pancreatitis. Genetic testing (PRSS1, CFTR, SPINK1, and CTRC) was performed in all eligible patients with idiopathic pancreatitis between 2010 to 2015. Patients were classified into the following groups based on a review of medical records: (1) acute recurrent idiopathic pancreatitis (ARIP) with or without underlying chronic pancreatitis; (2) idiopathic chronic pancreatitis (ICP) without a history of ARP; (3) an unexplained first episode of acute pancreatitis (AP)<35 years of age; and (4) family history of pancreatitis. Logistic regression analysis was used to determine the factors associated with pathogenic genetic variants. Among 197 ARIP and/or ICP patients evaluated from 2010 to 2015, 134 underwent genetic testing. A total of 88 pathogenic genetic variants were found in 64 (47.8%) patients. Pathogenic genetic variants were identified in 58, 63, and 27% of patients with ARIP, an unexplained first episode of AP <35 years of age, and ICP without ARP, respectively. ARIP (OR: 18.12; 95% CI: 2.16-151.87; P=0.008) and an unexplained first episode of AP<35 years of age (OR: 2.46; 95% CI: 1.18-5.15; P=0.017), but not ICP, were independently associated with pathogenic genetic variants in the adjusted analysis. Pathogenic genetic variants are most likely to be identified in patients with ARIP and an unexplained first episode of AP<35 years of age. Genetic testing in these patient populations may delineate an etiology and prevent unnecessary diagnostic testing and procedures.

Health information exchange reduces repeated diagnostic imaging for back pain.

PubMed

Bailey, James E; Pope, Rebecca A; Elliott, Elizabeth C; Wan, Jim Y; Waters, Teresa M; Frisse, Mark E

2013-07-01

This study seeks to determine whether health information exchange reduces repeated diagnostic imaging and related costs in emergency back pain evaluation. This was a longitudinal data analysis of health information exchange patient-visit data. All repeated emergency department (ED) patient visits for back pain with previous ED diagnostic imaging to a Memphis metropolitan area ED between August 1, 2007, and July 31, 2009, were included. Use of a regional health information exchange by ED personnel to access the patient's record during the emergency visit was the primary independent variable. Main outcomes included repeated lumbar or thoracic diagnostic imaging (radiograph, computed tomography [CT], or magnetic resonance imaging [MRI]) and total patient-visit estimated cost. One hundred seventy-nine (22.4%) of the 800 qualifying repeated back pain visits resulted in repeated diagnostic imaging (radiograph 84.9%, CT 6.1%, and MRI 9.5%). Health information exchange use in the study population was low, at 12.5%, and health care providers as opposed to administrative/nursing staff accounted for 80% of the total health information exchange use. Health information exchange use by any ED personnel was associated with reduced repeated diagnostic imaging (odds ratio 0.36; 95% confidence interval 0.18 to 0.71), as was physician or nurse practitioner health information exchange use (odds ratio 0.47; 95% confidence interval 0.23 to 0.96). No cost savings were associated with health information exchange use because of increased CT imaging when health care providers used health information exchange. Health information exchange use is associated with 64% lower odds of repeated diagnostic imaging in the emergency evaluation of back pain. Health information exchange effect on estimated costs was negligible. More studies are needed to evaluate specific strategies to increase health information exchange use and further decrease potentially unnecessary diagnostic imaging and associated costs of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Diagnostic utility, safety, and cost-effectiveness of emergency department-initiated early scheduled technetium-99m single photon emission computed tomography imaging followed by expedited outpatient cardiac clinic visits in acute chest pain syndromes.

PubMed

Wong, Raymond C; Sinha, Arvind Kumar; Mahadevan, Malcolm; Yeo, Tiong Cheng

2010-09-01

Conventional emergency department (EMD) approach to triaging acute chest pain syndromes may lead to unnecessary admissions, resulting to in-hospital bed occupancy and increased healthcare costs. We explore the diagnostic utility of early (less than a week) outpatient scheduled single photon emission computed tomography (SPECT) in intermediate-risk chest pain subjects who presented to EMD with non-diagnostic electrocardiogram and negative serum troponin level. Additionally, we intend to study the safety and cost-effectiveness of such a strategy. We conduct a prospective, non-randomized study of 108 subjects who fit the inclusion criteria. After SPECT studies, all subjects were evaluated in the cardiac clinic within 2 weeks of EMD visits. Final diagnosis of coronary artery disease and subsequent disposition to standard medical therapy or follow-on angiography were decided by incorporating pre-test clinical data and SPECT results. Adverse events defined as myocardial infarction and cardiac death was tracked between EMD visit and eventual therapy (either medical therapy or coronary revascularization). Finally, cost-effectiveness was determined based on estimated cost and days of hospitalization saved between standard strategies of ward admission for further evaluation versus the present early outpatient SPECT-based workflow. Among 108 subjects (mean age 58 years, 59% male) included for analysis, 82 (76%) had normal perfusion status. There was no statistical difference in baseline characteristics and prior ischemic heart disease history between groups. In the 26 abnormal perfusion subjects, seven had follow-on coronary angiography in which three were found to have significant stenotic coronary lesions, but only one had intervention performed. There was an unscheduled coronary angiography in the normal perfusion group that yielded normal coronary anatomy. There was no adverse clinical event in both groups. Compared with standard strategy, early outpatient SPECT initiated by EMD physicians followed by cardiac clinic evaluation resulted in 2.9 days of hospitalization or $781.23 saved per patient per EMD visit. EMD-initiated early SPECT studies followed by cardiac clinic evaluation in intermediate-risk acute chest pain syndromes with non-diagnostic ECG and negative serum troponin levels carries excellent diagnostic and therapeutic utility, in addition to being safe and cost-effective.

Diagnosis and management of differentiated thyroid cancer using molecular biology.

PubMed

Witt, Robert L; Ferris, Robert L; Pribitkin, Edmund A; Sherman, Steven I; Steward, David L; Nikiforov, Yuri E

2013-04-01

To define molecular biology in clinical practice for diagnosis, surgical management, and prognostication of differentiated thyroid cancer. Ovid Medline 2006-2012 Manuscripts with clinical correlates. Papillary thyroid carcinomas harbor point mutations of the BRAF and RAS genes or RET/PTC rearrangements, all of which activate the mitogen-activated protein kinase pathway. These mutually exclusive mutations are found in 70% of PTC. BRAF mutation is found in 45% of papillary thyroid cancer and is highly specific. Follicular carcinomas are known to harbor RAS mutation or PAX8/PPARγ rearrangement. These mutations are also mutually exclusive and identified in 70% of follicular carcinomas. Molecular classifiers measure the expression of a large number of genes on a microarray chip providing a substantial negative predictive value pending further validation. 1) 20% to 30% of cytologically classified Follicular Neoplasms and Follicular Lesion of Undetermined Significance collectively are malignant on final pathology. Approximately 70% to 80% of thyroid lobectomies performed solely for diagnostic purposes are benign. Molecular alteration testing may reduce the number of unnecessary thyroid procedures, 2) may reduce the number of completion thyroidectomies, and 3) may lead to more individualized operative and postoperative management. Molecular testing for BRAF, RAS, RET/PTC, and PAX8/PPARγ for follicular lesion of undetermined significance and follicular neoplasm improve specificity, whereas molecular classifiers may add negative predictive value to fine needle aspiration diagnosis. Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.

Canine distemper virus antigen detection in external epithelia of recently vaccinated, sick dogs by fluorescence microscopy is a valuable prognostic indicator.

PubMed

Kapil, Sanjay; Neel, Tina

2015-02-01

Currently, there are no reliable predictors of the clinical outcomes of domesticated dogs that have been recently vaccinated against canine distemper virus (CDV) and develop respiratory disease. In this study, vaccinated dogs from Oklahoma City that were showing clinical signs of respiratory disease were evaluated for CDV antigen using a direct fluorescent antibody test (FAT). Clinical outcomes after standard symptomatic therapy for respiratory disease were recorded, and a statistical analysis of the results was performed. We present our study showing that CDV FAT results were predictive of clinical recovery (prognostic indicator, prospects of clinical recovery) among vaccinated dogs showing clinical signs of respiratory disease. Negative CDV FAT results equated to 80% chances of recovery after symptomatic therapy, compared to 55% chances of recovery when the CDV FAT results were positive. Based on the results of this study, we show that veterinarians can make better informed decisions about the clinical outcomes of suspected CDV cases, with 2-h turnaround times, by using the CDV FAT. Thus, antemortem examination with the CDV FAT on external epithelia of recently vaccinated, sick dogs is a clinically useful diagnostic test and valuable prognostic indicator for veterinarians. Application of the CDV FAT to these samples avoids unnecessary euthanasia of dogs with suspected CDV. Copyright © 2015, American Society for Microbiology. All Rights Reserved.

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema.

PubMed

Rodríguez Suárez, Pedro; Freixinet Gilart, Jorge; Hernández Pérez, José María; Hussein Serhal, Mohamed; López Artalejo, Antonio

2012-07-01

We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ2 and Fisher exact test. The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit.

Intraosseous calcium migration in calcifying tendinitis: a rare cause of single sclerotic injury in the humeral head (2010: 2b).

PubMed

Martin, S; Rapariz, J M

2010-05-01

Intratendinous deposits of hydroxyapatite crystals are very common, particularly in the rotator cuff. In rare cases, the calcium located in the thickness of the supraspinatus tendon can suffer intraosseous migration into the greater tuberosity. We present a case of this rare entity: a 28-year-old patient who attended with pain and functional weakness in the left shoulder. The plain radiograph showed a sclerotic lesion in the greater tuberosity of the humeral head with a radiolucent halo. The MRI showed a lytic lesion containing the calcium inside and associated with an extensive pattern of oedema of the accompanying bone marrow. A plain radiograph taken 6 months before showed a calcifying tendinitis in the thickness of the supraspinatus tendon. A large number of entities can present as single sclerotic lesions of the humeral head. The diagnostic key lies in the existence of the calcifying tendinitis in the earlier study. The treatment of this disease consists of surgical removal of the calcium. The recognition of this entity is important to avoid unnecessary complementary tests and aggressive surgery, given that the surgical treatment is curative and leads to disappearance of the symptoms.

Biomarkers for ALK and ROS1 in Lung Cancer: Immunohistochemistry and Fluorescent In Situ Hybridization.

PubMed

Luk, Peter P; Selinger, Christina I; Mahar, Annabelle; Cooper, Wendy A

2018-06-14

- A small proportion of non-small cell lung cancers harbor rearrangements of ALK or ROS1 genes, and these tumors are sensitive to targeted tyrosine kinase inhibitors. It is crucial for pathologists to accurately identify tumors with these genetic alterations to enable patients to access optimal treatments and avoid unnecessary side effects of less effective agents. Although a number of different techniques can be used to identify ALK- and ROS1-rearranged lung cancers, immunohistochemistry and fluorescence in situ hybridization are the mainstays. - To review the role of immunohistochemistry in assessment of ALK and ROS1 rearrangements in lung cancer, focusing on practical issues in comparison with other modalities such as fluorescence in situ hybridization. - This manuscript reviews the current literature on ALK and ROS1 detection using immunohistochemistry and fluorescence in situ hybridization as well as current recommendations. - Although fluorescence in situ hybridization remains the gold standard for detecting ALK and ROS1 rearrangement in non-small cell lung cancer, immunohistochemistry plays an important role and can be an effective screening method for detection of these genetic alterations, or a diagnostic test in the setting of ALK.

Rate-Related Left Bundle Branch Block and Cardiac Memory in a Patient with Bradycardia: Case Report and Literature Review.

PubMed

Seibolt, Luke; Maestas, Camila; Lazkani, Mohamad; Fatima, Umaima; Loli, Akil; Chesser, Michael

2018-06-19

Rate-related left bundle branch block (LBBB) is a well-studied phenomenon. Cardiac memory is another physiologic phenomenon in which T-wave abnormalities occur in the absence of ischemia. The association between these two phenomena has been described in several case reports. A literature review was performed through OVID and Pubmed, where at total of 93 cases of rate- related LBBB were identified. Cases were reviewed and data were collected on rates of appearance and disappearance as well as the presence or absence of cardiac memory. There is some overlap in the rate at which LBBB appear. Cardiac memory is associated with rate-related LBBB in several cases but its true prevalence is unknown. Cardiac memory is a phenomenon that is well described in the literature but is often under-recognized in clinical practice. As a consequence of overlooking this phenomenon and not including cardiac memory in the differential when T-wave abnormalities are observed, patients may be subjected to unnecessary invasive diagnostic testing. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Demonstration of Sensor Data Integration Across Naval Aviation Maintenance

DTIC Science & Technology

2018-02-01

With expedited fault detection, fewer unnecessary parts would need to be ordered, saving time and money . Recommendations Based on our findings...level maintainer. These notes were included in every MAF in the “corrective action” block and were unformatted free -text. Out of the 70 repairs, only...translates to fewer unnecessary parts ordered, a reduction in the money spent on unnecessary parts, and a reduction of unnecessary logistic delays

Development of a thyroid function strategy for general practice.

PubMed Central

Ramachandran, S; Milles, J J; Wells, M B; Hall, R A

1998-01-01

A study was carried out to investigate a thyroid stimulating hormone (TSH) frontline strategy that could potentially result in a more straightforward interpretation of thyroid function tests, a reduction in the number of inappropriate referrals to medical outpatients, an improvement in the 'turnaround time' of results, and a reduction in the number of unnecessary tests carried out, thereby reducing costs. PMID:10071403

The Hundred Person Wellness Project and Google's Baseline Study: medical revolution or unnecessary and potentially harmful over-testing?

PubMed

Diamandis, Eleftherios P

2015-01-09

The Hundred Person Wellness Project is an ambitious pilot undertaking, which aims to intensely monitor 100 individuals over 10 months. Patients with abnormal findings will be treated, in hopes that this early intervention will avoid, or delay, symptomatic disease. Google's "Baseline Study" is of similar scope and will enroll 10,000 people over 2 to 3 years. I here speculate that these approaches will likely not be effective in preventing disease, but instead, lead to unnecessary and potentially harmful interventions. Examples from the cancer screening experience over the last 30 years are provided, which show that intensive testing may uncover indolent disease or incidental findings which, when treated, may cause more harm than good. Additional examples show that aggressive treatments for cancer and other diseases do not always lead to better patient outcomes. I conclude that the recent advances in omics provide us with unprecedented opportunities for high content clinical testing, but such testing should be used with caution to avoid the harmful consequences of over-diagnosis and over-treatment. Despite the detailed rebuttals by Hood and colleagues in another commentary in BMC Medicine, time will show the actual benefits and harms of these ambitious initiatives.

Placental growth factor (alone or in combination with soluble fms-like tyrosine kinase 1) as an aid to the assessment of women with suspected pre-eclampsia: systematic review and economic analysis.

PubMed

Frampton, Geoff K; Jones, Jeremy; Rose, Micah; Payne, Liz

2016-11-01

Pre-eclampsia (PE) prediction based on blood pressure, presence of protein in the urine, symptoms and laboratory test abnormalities can result in false-positive diagnoses. This may lead to unnecessary antenatal admissions and preterm delivery. Blood tests that measure placental growth factor (PlGF) or the ratio of soluble fms-like tyrosine kinase 1 (sFlt-1) to PlGF could aid prediction of PE if either were added to routine clinical assessment or used as a replacement for proteinuria testing. To evaluate the diagnostic accuracy and cost-effectiveness of PlGF-based tests for patients referred to secondary care with suspected PE in weeks 20-37 of pregnancy. Systematic reviews and an economic analysis. Bibliographic databases including MEDLINE, EMBASE, Web of Science and The Cochrane Library and Database of Abstracts of Reviews of Effects were searched up to July 2015 for English-language references. Conferences, websites, systematic reviews and confidential company submissions were also accessed. Systematic reviews of test accuracy and economic studies were conducted to inform an economic analysis. Test accuracy studies were required to include women with suspected PE and report quantitatively the accuracy of PlGF-based tests; their risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. The economic studies review had broad eligibility criteria to capture any types of economic analysis; critical appraisal employed standard checklists consistent with National Institute for Health and Care Excellence criteria. Study selection, critical appraisal and data extraction in both reviews were performed by two reviewers. An independent economic analysis was conducted based on a decision tree model, using the best evidence available. The model evaluates costs (2014, GBP) from a NHS and Personal Social Services perspective. Given the short analysis time horizon, no discounting was undertaken. Four studies were included in the systematic review of test accuracy: two on Alere's Triage ® PlGF test (Alere, Inc., San Diego, CA, USA) for predicting PE requiring delivery within a specified time and two on Roche Diagnostics' Elecsys ® sFlt-1 to PlGF ratio test (Roche Diagnostics GmbH, Mannheim, Germany) for predicting PE within a specified time. Three studies were included in the systematic review of economic studies, and two confidential company economic analyses were assessed separately. Study heterogeneity precluded meta-analyses of test accuracy or cost-analysis outcomes, so narrative syntheses were conducted to inform the independent economic model. The model predicts that, when supplementing routine clinical assessment for rule-out and rule-in of PE, the two tests would be cost-saving in weeks 20-35 of gestation, and marginally cost-saving in weeks 35-37, but with minuscule impact on quality of life. Length of neonatal intensive care unit stay was the most influential parameter in sensitivity analyses. All other sensitivity analyses had negligible effects on results. No head-to-head comparisons of the tests were identified. No studies investigated accuracy of PlGF-based tests when used as a replacement for proteinuria testing. Test accuracy studies were found to be at high risk of clinical review bias. The Triage and Elecsys tests would save money if added to routine clinical assessment for PE. The magnitude of savings is uncertain, but the tests remain cost-saving under worst-case assumptions. Further research is required to clarify how the test results would be interpreted and applied in clinical practice. This study is registered as PROSPERO CRD42015017670. The National Institute for Health Research Health Technology Assessment programme.

[The interplay of diagnostic and antimicrobial stewardship for the management of septic patients: the Tuscan model.

PubMed

Forni, Silvia; Toccafondi, Giulio; Viaggi, Bruno; Grazzini, Maddalena; D'Arienzo, Sara; Gemmi, Fabrizio; Vannucci, Andrea; Tulli, Giorgio

2018-02-01

Antimicrobial resistance is a global threat caused by the rapid spread of multiresistant microorganisms. Antimicrobial stewardship (AS) is a coordinated intervention designed to improve the appropriate use of antimicrobials by promoting the selection of the optimal drug regimen, dose, duration of therapy and route of administration. AS programs have proved effective in reducing antimicrobial resistance, inappropriate antimicrobial use and in improving patient outcomes. Recently developed rapid diagnostic technologies in microbiology (RDTM) allows a faster and etiological diagnosis of infection and a reduction in the use of unnecessary empirical therapies. This may result in important advancement in time-critical care pathways for septic patients. Nevertheless, RDTM are costly and if not rationally positioned may consume resources and hinder the efficacy of AS programs. In this regard, Tuscany Region is engaged in designing, through a systemic approach, an effective high-quality clinical microbiological service grid. In order to develop a sustainable and equitable model for integrating diagnostic and antimicrobial stewardship we conducted a survey in the regional network of 14 microbiological laboratories. The results shows that in order to develop a sustainable service we need to improve the communication at the interface between laboratories and care unit, harmonize the time windows for processing samples and to devise a robust score for stratifying patient with suspected sepsis.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).

PubMed

Bhattacharyya, Neil; Gubbels, Samuel P; Schwartz, Seth R; Edlow, Jonathan A; El-Kashlan, Hussam; Fife, Terry; Holmberg, Janene M; Mahoney, Kathryn; Hollingsworth, Deena B; Roberts, Richard; Seidman, Michael D; Steiner, Robert W Prasaad; Do, Betty Tsai; Voelker, Courtney C J; Waguespack, Richard W; Corrigan, Maureen D

2017-03-01

Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial.

PubMed

Arakaki, Ryan Y; Strazzula, Lauren; Woo, Elaine; Kroshinsky, Daniela

2014-10-01

Cellulitis is a common and costly problem, often diagnosed in the outpatient setting. Many cutaneous conditions may clinically mimic cellulitis, but little research has been done to assess the magnitude of the problem. To determine if obtaining dermatology consultations in the outpatient primary care setting could assist in the diagnosis of pseudocellulitic conditions and reduce the rate of unnecessary antibiotic use. Nonblinded randomized clinical trial of competent adults who were diagnosed as having cellulitis by their primary care physicians (PCPs), conducted at outpatient internal medical primary care offices affiliated with a large academic medical center. Outpatient dermatology consultation. Primary outcomes were final diagnosis, antibiotic use, and need for hospitalization. A total of 29 patients (12 male and 17 female) were enrolled for participation in this trial. Nine patients were randomized to continue with PCP management (control group), and 20 patients were randomized to receive a dermatology consultation (treatment group). Of the 20 patients in the dermatology consultation group, 2 (10%) were diagnosed as having cellulitis. In the control group, all 9 patients were diagnosed as having cellulitis by PCPs, but dermatologist evaluation determined that 6 (67%) of these patients had a psuedocellulitis rather than true infection. All 9 patients (100%) in the control group were treated for cellulitis with antibiotics vs 2 patients (10%) in the treatment group (P < .001). One patient in the control group was hospitalized. All patients in the treatment group reported improvement of their cutaneous condition at the 1-week follow-up examination. Dermatology consultation in the primary care setting improves the diagnostic accuracy of suspected cellulitis and decreases unnecessary antibiotic use in patients with pseudocellulitic conditions. Obtaining an outpatient dermatology consultation may be a cost-effective strategy that improves quality of care. clinicaltrials.gov Identifier:NCT01795092.

Fast and Noninvasive Characterization of Suspicious Lesions Detected at Breast Cancer X-Ray Screening: Capability of Diffusion-weighted MR Imaging with MIPs.

PubMed

Bickelhaupt, Sebastian; Laun, Frederik B; Tesdorff, Jana; Lederer, Wolfgang; Daniel, Heidi; Stieber, Anne; Delorme, Stefan; Schlemmer, Heinz-Peter

2016-03-01

To evaluate the ability of a diagnostic abbreviated magnetic resonance (MR) imaging protocol consisting of maximum intensity projections (MIPs) from diffusion-weighted imaging with background suppression (DWIBS) and unenhanced morphologic sequences to help predict the likelihood of malignancy on suspicious screening x-ray mammograms, as compared with an abbreviated contrast material-enhanced MR imaging protocol and a full diagnostic breast MR imaging protocol. This prospective institutional review board-approved study included 50 women (mean age, 57.1 years; range, 50-69 years), who gave informed consent and who had suspicious screening mammograms and an indication for biopsy, from September 2014 to January 2015. Before biopsy, full diagnostic contrast-enhanced MR imaging was performed that included DWIBS (b = 1500 sec/mm(2)). Two abbreviated protocols (APs) based on MIPs were evaluated regarding the potential to exclude malignancy: DWIBS (AP1) and subtraction images from the first postcontrast and the unenhanced series (AP2). Diagnostic indexes of both methods were examined by using the McNemar test and were compared with those of the full diagnostic protocol and histopathologic findings. Twenty-four of 50 participants had a breast carcinoma. With AP1 (DWIBS), the sensitivity was 0.92 (95% confidence interval [CI]: 0.73, 0.98), the specificity was 0.94 (95% CI: 0.77, 0.99), the negative predictive value (NPV) was 0.92 (95% CI: 0.75, 0.99), and the positive predictive value (PPV) was 0.93 (95% CI: 0.75, 0.99). The mean reading time was 29.7 seconds (range, 4.9-110.0 seconds) and was less than 3 seconds (range, 1.2-7.6 seconds) in the absence of suspicious findings on the DWIBS MIPs. With the AP2 protocol, the sensitivity was 0.85 (95% CI: 0.78, 0.95), the specificity was 0.90 (95% CI: 0.72, 0.97), the NPV was 0.87 (95% CI: 0.69, 0.95), the PPV was 0.89 (95% CI: 0.69, 0.97), and the mean reading time was 29.6 seconds (range, 6.0-100.0 seconds). Unenhanced diagnostic MR imaging (DWIBS mammography), with an NPV of 0.92 and an acquisition time of less than 7 minutes, could help exclude malignancy in women with suspicious x-ray screening mammograms. The method has the potential to reduce unnecessary invasive procedures and emotional distress for breast cancer screening participants if it is used as a complement after the regular screening clarification procedure.

Analytical performance of a bronchial genomic classifier.

PubMed

Hu, Zhanzhi; Whitney, Duncan; Anderson, Jessica R; Cao, Manqiu; Ho, Christine; Choi, Yoonha; Huang, Jing; Frink, Robert; Smith, Kate Porta; Monroe, Robert; Kennedy, Giulia C; Walsh, P Sean

2016-02-26

The current standard practice of lung lesion diagnosis often leads to inconclusive results, requiring additional diagnostic follow up procedures that are invasive and often unnecessary due to the high benign rate in such lesions (Chest 143:e78S-e92, 2013). The Percepta bronchial genomic classifier was developed and clinically validated to provide more accurate classification of lung nodules and lesions that are inconclusive by bronchoscopy, using bronchial brushing specimens (N Engl J Med 373:243-51, 2015, BMC Med Genomics 8:18, 2015). The analytical performance of the Percepta test is reported here. Analytical performance studies were designed to characterize the stability of RNA in bronchial brushing specimens during collection and shipment; analytical sensitivity defined as input RNA mass; analytical specificity (i.e. potentially interfering substances) as tested on blood and genomic DNA; and assay performance studies including intra-run, inter-run, and inter-laboratory reproducibility. RNA content within bronchial brushing specimens preserved in RNAprotect is stable for up to 20 days at 4 °C with no changes in RNA yield or integrity. Analytical sensitivity studies demonstrated tolerance to variation in RNA input (157 ng to 243 ng). Analytical specificity studies utilizing cancer positive and cancer negative samples mixed with either blood (up to 10 % input mass) or genomic DNA (up to 10 % input mass) demonstrated no assay interference. The test is reproducible from RNA extraction through to Percepta test result, including variation across operators, runs, reagent lots, and laboratories (standard deviation of 0.26 for scores on > 6 unit scale). Analytical sensitivity, analytical specificity and robustness of the Percepta test were successfully verified, supporting its suitability for clinical use.

Alternative approaches for vertebrate ecotoxicity tests in the ...

EPA Pesticide Factsheets

The need for alternative approaches to the use of vertebrate animals for hazard assessing chemicals and pollutants has become of increasing importance. It is now the first consideration when initiating a vertebrate ecotoxicity test, to ensure that unnecessary use of vertebrate organisms is minimised wherever possible. For some regulatory purposes, the use of vertebrate organisms for environmental risk assessments (ERA) has even been banned, and in other situations the numbers of organisms tested has been dramatically reduced, or the severity of the procedure refined. However, there is still a long way to go to achieve replacement of vertebrate organisms to generate environmental hazard data. The development of animal alternatives is not just based on ethical considerations but also to reduce the cost of performing vertebrate ecotoxicity tests and in some cases to provide better information aimed at improving ERAs. The present focus paper provides an overview of the considerable advances that have been made towards alternative approaches for ecotoxicity assessments over the last few decades. The need for alternative approaches to the use of vertebrate animals for hazard assessing chemicals and pollutants has become of increasing importance. It is now the first consideration when initiating a vertebrate ecotoxicity test, to ensure that unnecessary use of vertebrate organisms is minimised wherever possible. For some regulatory purposes, the use of vertebrate organi

Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients.

PubMed

Gertz, Zachary M; O'Donnell, William; Raina, Amresh; Balderston, Jessica R; Litwack, Andrew J; Goldberg, Lee R

2016-10-15

The rising use of imaging cardiac stress tests has led to potentially unnecessary testing. Interventions designed to reduce inappropriate stress testing have focused on the ambulatory setting. We developed a computerized order entry tool intended to reduce the use of imaging cardiac stress tests and improve appropriate use in hospitalized patients. The tool was evaluated using preimplementation and postimplementation cohorts at a single urban academic teaching hospital. All hospitalized patients referred for testing were included. The co-primary outcomes were the use of imaging stress tests as a percentage of all stress tests and the percentage of inappropriate tests, compared between the 2 cohorts. There were 478 patients in the precohort and 463 in the postcohort. The indication was chest pain in 66% and preoperative in 18% and was not significantly different between groups. The use of nonimaging stress tests increased from 4% in the pregroup to 15% in the postgroup (p <0.001). Among very low-risk chest pain patients, the use of nonimaging stress tests increased from 7% to 25% (p <0.001). Inappropriate testing did not change significantly between groups (12% vs 11%). Inappropriate tests were most often preoperative evaluations (83%). In conclusion, our computerized ordering tool significantly increased the use of nonimaging cardiac stress tests and reduced the use of imaging tests yet was not able to reduce inappropriate use. Our study highlights the differences in cardiac stress testing between hospitalized and ambulatory patients. Copyright © 2016 Elsevier Inc. All rights reserved.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis.

PubMed

Shen, Bo; Shermock, Kenneth M; Fazio, Victor W; Achkar, Jean-Paul; Brzezinski, Aaron; Bevins, Charles L; Bambrick, Marlene L; Remzi, Feza H; Lashner, Bret A

2003-11-01

Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis. Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data. Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses. Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.

Pepsin in saliva for the diagnosis of gastro-oesophageal reflux disease.

PubMed

Hayat, Jamal O; Gabieta-Somnez, Shirley; Yazaki, Etsuro; Kang, Jin-Yong; Woodcock, Andrew; Dettmar, Peter; Mabary, Jerry; Knowles, Charles H; Sifrim, Daniel

2015-03-01

Current diagnostic methods for gastro-oesophageal reflux disease (GORD) have moderate sensitivity/specificity and can be invasive and expensive. Pepsin detection in saliva has been proposed as an 'office-based' method for GORD diagnosis. The aims of this study were to establish normal values of salivary pepsin in healthy asymptomatic subjects and to determine its value to discriminate patients with reflux-related symptoms (GORD, hypersensitive oesophagus (HO)) from functional heartburn (FH). 100 asymptomatic controls and 111 patients with heartburn underwent MII-pH monitoring and simultaneous salivary pepsin determination on waking, after lunch and dinner. Cut-off value for pepsin positivity was 16 ng/mL. Patients were divided into GORD (increased acid exposure time (AET), n=58); HO (normal AET and + Symptom Association Probability (SAP), n=26) and FH (normal AET and-SAP, n=27). 1/3 of asymptomatic subjects had pepsin in saliva at low concentration (0(0-59)ng/mL). Patients with GORD and HO had higher prevalence and pepsin concentration than controls (HO, 237(52-311)ng/mL and GORD, 121(29-252)ng/mL)(p<0.05). Patients with FH had low prevalence and concentration of pepsin in saliva (0(0-40) ng/mL). A positive test had 78.6% sensitivity and 64.9% specificity for diagnosis of GORD+HO (likelihood ratio: 2.23). However, one positive sample with >210 ng/mL pepsin suggested presence of GORD+HO with 98.2% specificity (likelihood ratio: 25.1). Only 18/84 (21.4%) of GORD+HO patients had 3 negative samples. In patients with symptoms suggestive of GORD, salivary pepsin testing may complement questionnaires to assist office-based diagnosis. This may lessen the use of unnecessary antireflux therapy and the need for further invasive and expensive diagnostic methods. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Pericarditis and pericardial effusion: management update.

PubMed

Sparano, Dina M; Ward, R Parker

2011-12-01

Prompt recognition of the signs and symptoms of pericardial disease is critical so that appropriate treatments can be initiated. Acute pericarditis has a classical presentation, including symptoms, physical examination findings, and electrocardiography abnormalities. Early recognition of acute pericarditis will avoid unnecessary invasive testing and prompt therapies that provide rapid symptom relief. Non-steroidal anti-inflammatory drugs (NSAIDs) remain first-line therapy for uncomplicated acute pericarditis, although colchicine can be used concomitantly with NSAIDS as the first-line approach, particularly in severely symptomatic cases. Colchicine should be used in all refractory cases and as initial therapy in all recurrences. Aspirin should replace NSAIDS in pericarditis complicating acute myocardial infarction. Systemic corticosteroids can be used in refractory cases or in those with immune-mediated etiologies, although generally should be avoided due to a higher risk of recurrence. Pericardial effusions have many etiologies and the approach to diagnosis and therapy depends on clinical presentation. Pericardial tamponade is a life-threatening clinical diagnosis made on physical examination and supported by characteristic findings on diagnostic testing. Prompt diagnosis and management is critical. Treatment consists of urgent pericardial fluid drainage with a pericardial drain left in place for several days to help prevent acute recurrence. Analysis of pericardial fluid should be performed in all cases as it may provide clues to etiology. Consultation of cardiac surgery for pericardial window should be considered in recurrent cases and may be the first-line approach to malignant effusions, although acute relief of hemodynamic compromise must not be delayed. Constrictive pericarditis is associated with symptoms that mimic many other cardiac conditions. Thus, correct diagnosis is critical and involves identification of pericardial thickening or calcification in association with characteristic hemodynamic alterations using noninvasive and invasive diagnostic approaches. Constrictive physiology may occur transiently and resolve with medical therapy. In chronic cases, definitive therapy requires referral to an experienced surgeon for pericardiectomy.

Health economic assessment of Gd-EOB-DTPA MRI versus ECCM-MRI and multi-detector CT for diagnosis of hepatocellular carcinoma in China

PubMed Central

He, Xiaoning; Holtorf, Anke-Peggy; Rinde, Harald; Xie, Shuangshuang; Shen, Wen; Hou, Jiancun; Li, Xuehua; Li, Ziping; Lai, Jiaming; Wang, Yuting; Zhang, Lin; Wang, Jian; Li, Xuesong; Ma, Kuansheng; Ye, Feng; Ouyang, Han; Zhao, Hong

2018-01-01

Limited data exists in China on the comparative cost of gadolinium ethoxybenzyl diethylenetriamine magnetic resonance imaging (Gd-EOB-DTPA-MRI) with other imaging techniques. This study compared the total cost of Gd-EOB-DTPA-MRI with multidetector computed tomography (MDCT) and extracellular contrast media–enhanced MRI (ECCM-MRI) as initial imaging procedures in patients with suspected hepatocellular carcinoma (HCC). We developed a decision-tree model on the basis of the Chinese clinical guidelines for HCC, which was validated by clinical experts from China. The model compared the diagnostic accuracy and costs of alternative initial imaging procedures. Compared with MDCT and ECCM-MRI, Gd-EOB-DTPA-MRI imaging was associated with higher rates of diagnostic accuracy, i.e. higher proportions of true positives (TP) and true negatives (TN) with lower false positives (FP). Total diagnosis and treatment cost per patient after the initial Gd-EOB-DTPA-MRI evaluation was similar to MDCT (¥30,360 vs. ¥30,803) and lower than that reported with ECCM-MRI (¥30,360 vs. ¥31,465). Lower treatment cost after initial Gd-EOB-DTPA-MRI was driven by reduced utilization of confirmatory diagnostic procedures and unnecessary treatments. The findings reported that Gd-EOB-DTPA-MRI offered higher diagnostic accuracy compared with MDCT and ECCM-MRI at a comparable cost, which indicates Gd-EOB-DTPA-MRI could be the preferred initial imaging procedure for the diagnosis of HCC in China. PMID:29324837

Triage of women with low-grade cervical lesions--HPV mRNA testing versus repeat cytology.

PubMed

Sørbye, Sveinung Wergeland; Arbyn, Marc; Fismen, Silje; Gutteberg, Tore Jarl; Mortensen, Elin Synnøve

2011-01-01

In Norway, women with low-grade squamous intraepithelial lesions (LSIL) are followed up after six months in order to decide whether they should undergo further follow-up or be referred back to the screening interval of three years. A high specificity and positive predictive value (PPV) of the triage test is important to avoid unnecessary diagnostic and therapeutic procedures. At the University Hospital of North Norway, repeat cytology and the HPV mRNA test PreTect HPV-Proofer, detecting E6/E7 mRNA from HPV types 16, 18, 31, 33 and 45, are used in triage of women with ASC-US and LSIL. In this study, women with LSIL cytology in the period 2005-2008 were included (n = 522). Two triage methods were evaluated in two separate groups: repeat cytology only (n = 225) and HPV mRNA testing in addition to repeat cytology (n = 297). Histologically confirmed cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) was used as the study endpoint. Of 522 women with LSIL, 207 had biopsies and 125 of them had CIN2+. The sensitivity and specificity of repeat cytology (ASC-US or worse) were 85.7% (95% confidence interval (CI): 72.1, 92.2) and 54.4 % (95% CI: 46.9, 61.9), respectively. The sensitivity and specificity of the HPV mRNA test were 94.2% (95% CI: 88.7, 99.7) and 86.0% (95% CI: 81.5, 90.5), respectively. The PPV of repeat cytology was 38.4% (95% CI: 29.9, 46.9) compared to 67.0% (95% CI: 57.7, 76.4) of the HPV mRNA test. HPV mRNA testing was more sensitive and specific than repeat cytology in triage of women with LSIL cytology. In addition, the HPV mRNA test showed higher PPV. These data indicate that the HPV mRNA test is a better triage test for women with LSIL than repeat cytology.

Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests

PubMed Central

2012-01-01

Background Routine pre-operative tests for anesthesia management are often ordered by both anesthesiologists and surgeons for healthy patients undergoing low-risk surgery. The Theoretical Domains Framework (TDF) was developed to investigate determinants of behaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists’ and surgeons’ perceptions of ordering routine tests for healthy patients undergoing low-risk surgery. Methods Sixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Content analysis of physicians’ statements into the relevant theoretical domains was performed. Specific beliefs were identified by grouping similar utterances of the interview participants. Relevant domains were identified by noting the frequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence on the performance of the behaviour under investigation. Results Seven of the twelve domains were identified as likely relevant to changing clinicians’ behaviour about pre-operative test ordering for anesthesia management. Key beliefs were identified within these domains including: conflicting comments about who was responsible for the test-ordering (Social/professional role and identity); inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences); and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources). Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences). There were also conflicting comments about the potential consequences associated with reducing testing, from negative (delay or cancel patients’ surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs about consequences). Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation). Conclusion We identified key factors that anesthesiologists and surgeons believe influence whether they order pre-operative tests routinely for anesthesia management for a healthy adults undergoing low-risk surgery. These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering. PMID:22682612

The impact of rapid malaria diagnostic tests upon anti-malarial sales in community pharmacies in Gwagwalada, Nigeria

PubMed Central

2013-01-01

Background Rapid diagnostics tests for malaria (RDT) have become established as a practical solution to the challenges of parasitological confirmation of malaria before treatment in the public sector. However, little is known of their impact in private health sector facilities, such as pharmacies and drug shops. This study aimed to assess the incidence of malaria among unwell patients seeking anti-malarial treatment in two community pharmacies in Nigeria and measure the impact RDTs have on anti-malarial sales. Methods This was a comparison study of two pharmacies located in the suburbs of Gwagwalada, in the Federal Capital Territory of Nigeria, between May and July 2012. In the intervention arm, patients seeking to purchase anti-malarials had an RDT performed before treatment while the control pharmacy continued normal routine practice. Results A total of 1,226 participants were enrolled into the study. The incidence of malaria in the intervention arm (n = 619) was 13.6% and adolescent participants had a statistically significant higher incidence (26.0%) compared to adults (11.9%) (P = 0.001). A history of fever in the last 48 hours was associated with a statistically significant higher incidence of malaria (28.3%) (P < 0.001). Having a RDT test reduced the chance of purchasing an anti-malarial by 42% (95% CI: 38%-46%) compared to not having a test. 51.6% (276) of the study participants with a RDT negative result still purchased anti-malarials, especially if anti-malarials had been recommended by a health professional (58.9%) compared to self-referral (44.2%) (P = 0.001). Patients with RDT negative results were also more likely to purchase an anti-malarial if there was a reported malaria positive laboratory test prior to presentation (66.2%; P = 0.007), a history of fever in the last 48 hours (60.5%; P = 0.027), and primary school education or less (69.4%; P = 0.009). After adjusting for age group and gender differences, having at least a secondary school education reduced the chance of buying an anti-malarial (OR 0.504 (95% CI: 0.256-0.993)) compared to having primary education or lower. Conclusion The study highlights the enormous potential for improving appropriate prescription of anti-malarials in pharmacies and preventing unnecessary use of artemisinin combination therapy (ACT). PMID:24172163

The impact of rapid malaria diagnostic tests upon anti-malarial sales in community pharmacies in Gwagwalada, Nigeria.

PubMed

Ikwuobe, John O; Faragher, Brian E; Alawode, Gafar; Lalloo, David G

2013-10-30

Rapid diagnostics tests for malaria (RDT) have become established as a practical solution to the challenges of parasitological confirmation of malaria before treatment in the public sector. However, little is known of their impact in private health sector facilities, such as pharmacies and drug shops. This study aimed to assess the incidence of malaria among unwell patients seeking anti-malarial treatment in two community pharmacies in Nigeria and measure the impact RDTs have on anti-malarial sales. This was a comparison study of two pharmacies located in the suburbs of Gwagwalada, in the Federal Capital Territory of Nigeria, between May and July 2012. In the intervention arm, patients seeking to purchase anti-malarials had an RDT performed before treatment while the control pharmacy continued normal routine practice. A total of 1,226 participants were enrolled into the study. The incidence of malaria in the intervention arm (n = 619) was 13.6% and adolescent participants had a statistically significant higher incidence (26.0%) compared to adults (11.9%) (P = 0.001). A history of fever in the last 48 hours was associated with a statistically significant higher incidence of malaria (28.3%) (P < 0.001). Having a RDT test reduced the chance of purchasing an anti-malarial by 42% (95% CI: 38%-46%) compared to not having a test. 51.6% (276) of the study participants with a RDT negative result still purchased anti-malarials, especially if anti-malarials had been recommended by a health professional (58.9%) compared to self-referral (44.2%) (P = 0.001). Patients with RDT negative results were also more likely to purchase an anti-malarial if there was a reported malaria positive laboratory test prior to presentation (66.2%; P = 0.007), a history of fever in the last 48 hours (60.5%; P = 0.027), and primary school education or less (69.4%; P = 0.009). After adjusting for age group and gender differences, having at least a secondary school education reduced the chance of buying an anti-malarial (OR 0.504 (95% CI: 0.256-0.993)) compared to having primary education or lower. The study highlights the enormous potential for improving appropriate prescription of anti-malarials in pharmacies and preventing unnecessary use of artemisinin combination therapy (ACT).

Study on Unified Chaotic System-Based Wind Turbine Blade Fault Diagnostic System

NASA Astrophysics Data System (ADS)

Kuo, Ying-Che; Hsieh, Chin-Tsung; Yau, Her-Terng; Li, Yu-Chung

At present, vibration signals are processed and analyzed mostly in the frequency domain. The spectrum clearly shows the signal structure and the specific characteristic frequency band is analyzed, but the number of calculations required is huge, resulting in delays. Therefore, this study uses the characteristics of a nonlinear system to load the complete vibration signal to the unified chaotic system, applying the dynamic error to analyze the wind turbine vibration signal, and adopting extenics theory for artificial intelligent fault diagnosis of the analysis signal. Hence, a fault diagnostor has been developed for wind turbine rotating blades. This study simulates three wind turbine blade states, namely stress rupture, screw loosening and blade loss, and validates the methods. The experimental results prove that the unified chaotic system used in this paper has a significant effect on vibration signal analysis. Thus, the operating conditions of wind turbines can be quickly known from this fault diagnostic system, and the maintenance schedule can be arranged before the faults worsen, making the management and implementation of wind turbines smoother, so as to reduce many unnecessary costs.

Diagnostic medical imaging radiation exposure and risk of development of solid and hematologic malignancy.

PubMed

Fabricant, Peter D; Berkes, Marschall B; Dy, Christopher J; Bogner, Eric A

2012-05-01

Limiting patients' exposure to ionizing radiation during diagnostic imaging is of concern to patients and clinicians. Large single-dose exposures and cumulative exposures to ionizing radiation have been associated with solid tumors and hematologic malignancy. Although these associations have been a driving force in minimizing patients' exposure, significant risks are found when diagnoses are missed and subsequent treatment is withheld. Therefore, based on epidemiologic data obtained after nuclear and occupational exposures, dose exposure limits have been estimated. A recent collaborative effort between the US Food and Drug Administration and the American College of Radiology has provided information and tools that patients and imaging professionals can use to avoid unnecessary ionizing radiation scans and ensure use of the lowest feasible radiation dose necessary for studies. Further collaboration, research, and development should focus on producing technological advances that minimize individual study exposures and duplicate studies. This article outlines the research used to govern safe radiation doses, defines recent initiatives in decreasing radiation exposure, and provides orthopedic surgeons with techniques that may help decrease radiation exposure in their daily practice. Copyright 2012, SLACK Incorporated.

Inducible laryngeal obstruction during exercise: moving beyond vocal cords with new insights.

PubMed

Olin, James Tod; Clary, Matthew S; Deardorff, Emily H; Johnston, Kristina; Morris, Michael J; Sokoya, Mofiyinfolu; Staudenmayer, Herman; Christopher, Kent L

2015-02-01

Exercise as an important part of life for the health and wellness of children and adults. Inducible laryngeal obstruction (ILO) is a consensus term used to describe a group of disorders previously called vocal cord dysfunction, paradoxical vocal fold motion, and numerous other terms. Exercise-ILO can impair one's ability to exercise, can be confused with asthma, leading to unnecessary prescription of asthma controller and rescue medication, and results in increased healthcare resource utilization including (rarely) emergency care. It is characterized by episodic shortness of breath and noisy breathing that generally occurs at high work rates. The present diagnostic gold standard for all types of ILO is laryngoscopic visualization of inappropriate glottic or supraglottic movement resulting in airway narrowing during a spontaneous event or provocation challenge. A number of different behavioral techniques, including speech therapy, biofeedback, and cognitive-behavioral psychotherapy, may be appropriate to treat individual patients. A consensus nomenclature, which will allow for better characterization of patients, coupled with new diagnostic techniques, may further define the epidemiology and etiology of ILO as well as enable objective evaluation of therapeutic modalities.

Population-Based Assessment of a Biomarker-Based Screening Pathway to Aid Diagnosis of Monogenic Diabetes in Young-Onset Patients.

PubMed

Shields, Beverley M; Shepherd, Maggie; Hudson, Michelle; McDonald, Timothy J; Colclough, Kevin; Peters, Jaime; Knight, Bridget; Hyde, Chris; Ellard, Sian; Pearson, Ewan R; Hattersley, Andrew T

2017-08-01

Monogenic diabetes, a young-onset form of diabetes, is often misdiagnosed as type 1 diabetes, resulting in unnecessary treatment with insulin. A screening approach for monogenic diabetes is needed to accurately select suitable patients for expensive diagnostic genetic testing. We used C-peptide and islet autoantibodies, highly sensitive and specific biomarkers for discriminating type 1 from non-type 1 diabetes, in a biomarker screening pathway for monogenic diabetes. We studied patients diagnosed at age 30 years or younger, currently younger than 50 years, in two U.K. regions with existing high detection of monogenic diabetes. The biomarker screening pathway comprised three stages: 1 ) assessment of endogenous insulin secretion using urinary C-peptide/creatinine ratio (UCPCR); 2 ) if UCPCR was ≥0.2 nmol/mmol, measurement of GAD and IA2 islet autoantibodies; and 3 ) if negative for both autoantibodies, molecular genetic diagnostic testing for 35 monogenic diabetes subtypes. A total of 1,407 patients participated (1,365 with no known genetic cause, 34 with monogenic diabetes, and 8 with cystic fibrosis-related diabetes). A total of 386 out of 1,365 (28%) patients had a UCPCR ≥0.2 nmol/mmol, and 216 out of 386 (56%) were negative for GAD and IA2 and underwent molecular genetic testing. Seventeen new cases of monogenic diabetes were diagnosed (8 common Maturity Onset Diabetes of the Young [Sanger sequencing] and 9 rarer causes [next-generation sequencing]) in addition to the 34 known cases (estimated prevalence of 3.6% [51/1,407] [95% CI 2.7-4.7%]). The positive predictive value was 20%, suggesting a 1-in-5 detection rate for the pathway. The negative predictive value was 99.9%. The biomarker screening pathway for monogenic diabetes is an effective, cheap, and easily implemented approach to systematically screening all young-onset patients. The minimum prevalence of monogenic diabetes is 3.6% of patients diagnosed at age 30 years or younger. © 2017 by the American Diabetes Association.

Some Resentments and Fears of Pre Service Teachers

ERIC Educational Resources Information Center

Welter, Paul R.

1971-01-01

Typescript excerpts from group counseling sessions suggest that schools of education need to pitch their teaching and testing at higher cognitive levels. Giving primary attention to the bare knowledge or memory level is not only ineffective but also an unnecessary source of resentment among students. (Author)

Physical Fitness Testing by the U.S. Air Force Academy, 1955-1981

DTIC Science & Technology

1983-09-01

numerous knee and back injuries were incurred during 5BX testing causing the loss of productive man-hours. In one of Lt Colonel Cooper’s original...the test items will be changed periodically to prevent prospective candidates for admis- sion to the United States Air Force Academy from practic- ing...following text, reproduced in whole, is a careful consideration of all available PAE research through 1971. Its existence should prevent unnecessary

Faith community nursing demonstrates good stewardship of community benefit dollars through cost savings and cost avoidance.

PubMed

Brown, Ameldia R; Coppola, Patricia; Giacona, Marian; Petriches, Anne; Stockwell, Mary Ann

2009-01-01

Health systems seeking responsible stewardship of community benefit dollars supporting Faith Community Nursing Networks require demonstration of positive measurable health outcomes. Faith Community Nurses (FCNs) answer the call for measurable outcomes by documenting cost savings and cost avoidances to families, communities, and health systems associated with their interventions. Using a spreadsheet tool based on Medicare reimbursements and diagnostic-related groupings, 3 networks of FCNs have together shown more than 600 000 (for calendar year 2008) healthcare dollars saved by avoidance of unnecessary acute care visits and extended care placements. The cost-benefit ratio of support dollars to cost savings and cost avoidance demonstrates that support of FCNs is good stewardship of community benefit dollars.

Hyalinizing Trabecular Tumor of the Thyroid Gland, a Diagnostic Challenge in Fine-Needle Aspiration Cytology: Case Report.

PubMed

Rhee, Ye-Young; Jung, Hong Kyu; Kim, Se Hoon; Kim, Soo Hee

2018-06-11

Hyalinizing trabecular tumor (HTT) is a rare thyroid tumor with low to minimal malignant potential. HTT is often misinterpreted as other thyroid tumors, including papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma (MTC), on fine-needle aspiration (FNA) cytology, because of its overlapping cytologic features, such as nuclear grooves and intranulcear pseudoinclusions. Although cytopathologists cannot definitely conclude HTT by FNA cytology, suspicion of HTT is necessary to avoid misdiagnosing HTT as PTC or MTC and to avoid unnecessary aggressive treatment. Here, we report a case of HTT with novel cytologic features in CellPrep liquid based cytology that was diagnosed as suspicious for papillary carcinoma by FNA and finally diagnosed as HTT in the surgical specimen.

Spasm of the near reflex: A case report.

PubMed

Rhatigan, Maedbh; Byrne, Caroline; Logan, Patricia

2017-06-01

Spasm of the near reflex (SNR) is a triad of miosis, excess accommodation and excess convergence. Primary SNR is most often functional in origin We aim to highlight the clinical features which distinguish primary convergence from other conditions with a similar presentation but more sinister underlying aetiology, for example bilateral abducens nerve palsy. There is a paucity of published data on SNR, in particular diagnostic criteria and treatment. We report a case of SNR of functional origin in an otherwise healthy young female and discuss the clinical features that differentiate this condition from similar conditions with underlying neurological origin. SNR is predominantly a clinical diagnosis, and often leads to patients undergoing unnecessary investigations and sometimes treatment. Recognising the salient features that differentiate it could potentially avoid this.

[Central interdisciplinary emergency department. Organization of emergency medicine from the perspective of hospital management].

PubMed

Mayer, U; Debatin, J F

2011-04-01

The treatment of emergencies in a hospital should be organized in a central interdisciplinary emergency department (ER). It is the main entrance for all patients with acute illness or injuries. There are multiple advantages of such a central unit. Quality of treatment and economic efficiency is improved. The interdisciplinary diagnostics and treatment at one place prevents time-consuming and unnecessary transport. The fact that more complex diseases and injuries need specialized doctors in specific disciplines should be considered in personnel planning of the ER. To reinsure that the entire medical staff of the hospital is familiar with the daily routine and clinical pathways of the ER, doctors from other departments of the hospital should always be part of the ER team.

The HEART score is useful to predict cardiovascular risks and reduces unnecessary cardiac imaging in low-risk patients with acute chest pain.

PubMed

Dai, Siping; Huang, Bo; Zou, Yunliang; Guo, Jianbin; Liu, Ziyong; Pi, Dangyu; Qiu, Yunhong; Xiao, Chun

2018-06-01

The present study was to investigate whether the HEART score can be used to evaluate cardiovascular risks and reduce unnecessary cardiac imaging in China.Acute coronary syndrome patients with the thrombosis in myocardial infarction risk score < 2 were enrolled in the emergency department. Baseline data were collected and a HEART score was determined in each participant during the indexed emergency visit. Participants were follow-up for 30 days after discharge and the studied endpoints included acute myocardial infarction, cardiovascular mortality and all-cause mortality.A total of 244 patients were enrolled and 2 was loss of follow-up. The mean age was 50.4 years old and male patients accounted for 64.5%. Substernal pain and featured as pressure of the pain accounted for 34.3% and 39.3%, respectively. After 30 days' follow-up, no patient in the low-risk HEART score group and 2 patients (1.5%) in the high risk HEART score group had cardiovascular events. The sensitivity of HEART score to predict cardiovascular events was 100% and the specificity was 46.7%. The potential unnecessary cardiac testing was 46.3%. Cox proportional hazards regression analysis showed that per one category increase of the HEART score was associated with nearly 1.3-fold risk of cardiovascular events.In the low-risk acute chest pain patients, the HEART score is useful to physicians in evaluating the risk of cardiovascular events within the first 30 days. In addition, the HEART score is also useful in reducing the unnecessary cardiac imaging.

Tongue Blade Bite Test Predicts Mandible Fractures

PubMed Central

Neiner, John; Free, Rachael; Caldito, Gloria; Moore-Medlin, Tara; Nathan, Cherie-Ann

2015-01-01

The aim of the study is to evaluate the utility of a simple tongue blade bite test in predicting mandible fractures and use this test as an alternative screening tool for further workup. This is a retrospective chart review. An institutional review board approved the retrospective review of patients evaluated by the Department of Otolaryngology at a single institution for facial trauma performed from November 1, 2011, to February 27, 2014. Patients who had a bite test documented were included in the study. CT was performed in all cases and was used as the gold standard to diagnose mandible fractures. Variables analyzed included age, sex, fracture type/location on CT, bite test positivity, and operative intervention. A total of 86 patients met the inclusion criteria and of those 12 were pediatric patients. Majority of the patients were male (80.2%) and adult (86.0%; average age: 34.3 years). Fifty-seven patients had a negative bite test and on CT scans had no mandible fracture. Twenty-three patients had a positive bite test and a CT scan confirmed fracture. The bite test revealed a sensitivity of 88.5% (95% CI: 69.8–97.6%), specificity of 95.0% (95% CI:86.1–99%), positive predictive value [PPV] of 88.5% (95% CI: 69.8–97.6%), and negative predictive value [NPV] of 95.0% (95% CI: 86.1–99.0%). Among pediatric patients, the sensitivity was 100% (95% CI: 29.9–100%), specificity was 88.9% (95% CI: 68.4–100%), PPV was 75.0% (95% CI: 19.4–99.4%), and NPV was 100% (95% CI: 63.1–100%). The tongue blade bite test is a quick inexpensive diagnostic tool for the otolaryngologist with high sensitivity and specificity for predicting mandible fractures. In the pediatric population, where avoidance of unnecessary CT scans is of highest priority, a wider range of data collection should be undertaken to better assess its utility. PMID:27162567

Evaluation of antibiotic prescriptions for urinary tract infections in a geriatric rehabilitation unit.

PubMed

Afekouh, Hind; Baune, Patricia; De Falvelly, Diane; Guermah, Fatima; Ghitri, Saïda; Haber, Nicole

2017-03-01

Prescription of antibiotic in elderly patients must follow guidelines. to study the quality of antibiotic prescriptions for urinary tract infections (UTI) in the geriatric rehabilitation unit. Over a four-month period, all the antibiotics treatments prescribed for UTI in the rehabilitation ward were analyzed prospectively by medical experts and confronted with the recommendations of the local antibiotic guidelines. The methodology was based on Gyssens' algorithm. Treatments were considered appropriate if indication, choice of the molecule, duration and dose were approved by the experts, unnecessary if the indication was incorrect, and inappropriate in all other cases. The re-assessment of the prescription between 48 and 72 h was also evaluated. We reviewed 39 prescriptions. About half of all prescriptions (51.3%) was found to be unnecessary due to misdiagnosis, 16 prescriptions (41%) were considered inappropriate (2 for inadequate duration and 14 for inappropriate spectrum of activity, mainly with ceftriaxone prescriptions (9 cases)). Ten prescriptions (25.6%) were re-assessed between 48 and 72 hours after treatment initiation. According to this study, an improvement program was implemented. A diagnostic algorithm for UTI in elderly was drafted and will be integrated into the local guidelines. A supporting document for the re-assessment of the prescriptions 48-72h after treatment initiation was created. We decided to perform an evaluation of antibiotic prescriptions by the subcutaneous route.

Reduction in unnecessary red blood cell folate testing by restricting computerized physician order entry in the electronic health record.

PubMed

MacMillan, Thomas E; Gudgeon, Patrick; Yip, Paul M; Cavalcanti, Rodrigo B

2018-05-02

Red blood cell folate is a laboratory test with limited clinical utility. Previous attempts to reduce physician ordering of unnecessary laboratory tests, including folate, have resulted in only modest success. The objective of this study was to assess the effectiveness and impacts of restricting red blood cell folate ordering in the electronic health record. This was a retrospective observational study from January 2010 to December 2016 at a large academic healthcare network in Toronto, Canada. All inpatients and outpatients who underwent at least 1 red blood cell folate or vitamin B12 test during the study period were included. Red blood cell folate ordering was restricted to clincians in gastroenterology and hematology and was removed from other physicians' computerized order entry screen in the electronic health record in June 2013. Red blood cell folate testing decreased by 94.4% during the study, from a mean of 493.0 (SD 48.0) tests/month before intervention to 27.6 (SD 10.3) tests/month after intervention (P<.001). Restricting red blood cell folate ordering in the electronic health record resulted in a large and sustained reduction in red blood cell folate testing. Significant cost savings estimated at over a quarter-million dollars (CAD) over three years were achieved. There was no significant clinical impact of the intervention on the diagnosis of folate deficiency. Copyright © 2018. Published by Elsevier Inc.

Clinical Tests Combined with Color Doppler Versus Color Doppler Alone in Identifying Incompetent Perforator Veins of the Lower Limb: A Prospective Analytical Study.

PubMed

Sureshkumar, Sathasivam; Vignesh, Narayan; Venkatachalam, J; Vijayakumar, Chellappa; Sudharsanan, Sundaramurthi

2018-01-05

Background The color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement. Objective To compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb. Methods This was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg's test, multiple tourniquet tests and, the Fegan's tests were performed and incompetent perforators were marked on a template as 'C' to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as 'D'. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler 'D' marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as 'D' positive or 'C' and 'D' positive and were recorded in the specified proforma. Results It was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients. Conclusion A combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients.

A Single Center Evaluation of the Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging against Transperineal Prostate Mapping Biopsy: An Analysis of Men with Benign Histology and Insignificant Cancer following Transrectal Ultrasound Biopsy.

PubMed

Pal, Raj P; Ahmad, Ros; Trecartan, Shaun; Voss, James; Ahmed, Shaista; Bazo, Alvaro; Lloyd, Jon; Walton, Thomas J

2018-03-01

In this study we evaluated the diagnostic performance of transrectal ultrasound guided biopsy and multiparametric magnetic resonance imaging to detect prostate cancer against transperineal prostate mapping biopsy as the reference test. Transrectal ultrasound guided biopsy, multiparametric magnetic resonance imaging and transperineal prostate mapping biopsy were performed in 426 patients between April 2012 and January 2016. Patients initially underwent systematic 12 core transrectal ultrasound guided biopsy followed 3 months later by 1.5 Tesla, high resolution T2, diffusion-weighted, dynamic contrast enhanced multiparametric magnetic resonance imaging. Two specialist uroradiologists blinded to the results of transperineal prostate mapping biopsy allocated a PI-RADS™ (Prostate Imaging-Reporting and Data System) score to each multiparametric magnetic resonance imaging study. Transperineal prostate mapping biopsy with 5 mm interval sampling, which was performed within 6 months of multiparametric magnetic resonance imaging, served as the reference test. Transrectal ultrasound guided biopsy identified 247 of 426 patients with prostate cancer and 179 of 426 with benign histology. Transperineal prostate mapping biopsy detected prostate cancer in 321 of 426 patients. On transperineal prostate mapping biopsy 94 of 179 patients with benign transrectal ultrasound guided biopsy had prostate cancer and 95 of 247 with prostate cancer on transrectal ultrasound guided biopsy were identified with cancer of higher grade. Using a multiparametric magnetic resonance imaging PI-RADS score of 3 or greater to detect significant prostate cancer, defined as any core containing Gleason 4 + 3 or greater prostate cancer on transperineal prostate mapping biopsy, the ROC AUC was 0.754 (95% CI 0.677-0.819) with 87.0% sensitivity (95% CI 77.3-97.0), 55.3% specificity (95% CI 50.2-60.4) and 97.1% negative predictive value (95% CI 94.8-99.4). Multiparametric magnetic resonance imaging is a more accurate diagnostic test than transrectal ultrasound guided biopsy. However, a significant proportion of ISUP (International Society of Urological Pathology) Grade Group 2 prostate cancer remained undetected following multiparametric magnetic resonance imaging. Although multiparametric magnetic resonance imaging could avoid unnecessary biopsy in many patients with ISUP Grade Group 3 or greater prostate cancer, at less stringent definitions of significant cancer a substantial proportion of prostate cancer would remain undetected after multiparametric magnetic resonance imaging. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Clinical features of pathologic childhood aerophagia: early recognition and essential diagnostic criteria.

PubMed

Hwang, Jin-Bok; Choi, Won Joung; Kim, Jun Sik; Lee, Sang Yun; Jung, Chul-Ho; Lee, Young Hwan; Kam, Sin

2005-11-01

This study investigated the early recognition and diagnosis of pathologic childhood aerophagia to avoid unnecessary diagnostic approaches and serious complications. Between 1995 and 2003, data from 42 consecutive patients with pathologic childhood aerophagia, aged 2 to 16 years, were reviewed. An esophageal air sign was defined as an abnormal air shadow on the proximal esophagus adjacent to the trachea on a full-inflated chest radiograph. Of the 42 patients, the chief complaints were abdominal distention (52.4%), recurrent abdominal pain syndrome (21.4%), chronic diarrhea (11.9%), acute abdominal pain (7.1%) and others (7.2%). Mean symptom duration before diagnosis was 10.6 months (range, 1 to 60 months), and it exceeded 12 months for 16 (38.1%) patients. The clinical features common to all patients were abdominal distention that increased progressively during the day, increased flatus on sleep, increased bowel sound on auscultation and an air-distended stomach with increased gas in the small and large bowel by radiography. Visible or audible air swallowing (26.2%) and repetitive belching (9.5%) were also noted. Esophageal air sign was observed in 76.2% of the patients and in 9.7% of the controls (P=0.0001). The subgroups of pathologic childhood aerophagia divided by underlying associations were pathologic childhood aerophagia without severe mental retardation (76.2%), which consisted of psychological stresses and uncertain condition, and pathologic childhood aerophagia with severe mental retardation (23.8%). The common manifestations of pathologic childhood aerophagia may be its essential diagnostic criteria, and esophageal air sign may be useful for the early recognition of pathologic childhood aerophagia. Our observations show that the diagnostic clinical profiles suggested by Rome II criteria should be detailed and made clearer if they are to serve as diagnostic criteria for pathologic childhood aerophagia.

A reporting system for endometrial cytology: Cytomorphologic criteria-Implied risk of malignancy.

PubMed

Margari, Niki; Pouliakis, Abraham; Anoinos, Dionysios; Terzakis, Emmanouil; Koureas, Nikolaos; Chrelias, Charalampos; Marios Makris, George; Pappas, Assimakis; Bilirakis, Evripidis; Goudeli, Christina; Damaskou, Vasileia; Papantoniou, Nicolaos; Panayiotides, Ioannis; Karakitsos, Petros

2016-11-01

There have been various attempts to assess endometrial lesions on cytological material obtained via direct endometrial sampling. The majority of efforts focus on the description of cytological criteria that lead to classification systems resembling histological reporting formats. These systems have low reproducibility, especially in cases of atypical hyperplasia and well differentiated carcinomas. Moreover, they are not linked to the implied risk of malignancy. The material was collected from women examined at the outpatient department of four participating hospitals. We analyzed 866 consecutive, histologically confirmed cases. The sample collection was performed using the EndoGyn device, and processed via Liquid Based Cytology, namely ThinPrep technique. The diagnostic categories and criteria were established by two cytopathologists experienced in endometrial cytology; performance of the proposed reporting format was assessed on the basis of histological outcome; moreover, the implied risk of malignancy was calculated. The proposed six diagnostic categories are as follows: (i) nondiagnostic or unsatisfactory; (ii) without evidence of hyperplasia or malignancy; (iii) atypical cells of endometrium of undetermined significance; (iv) atypical cells of endometrium of low probability for malignancy; (v) atypical cells of endometrium of high probability for malignancy; and (vi) malignant. The risk of malignancy was 1.42% ± 0.98%, 44.44% ± 32.46% (nine cases), 4.30% ± 4.12%, 89.80% ± 8.47%, and 97.81% ± 2.45%, respectively. We propose a clinically oriented classification scheme consisting of diagnostic categories with well determined criteria. Each diagnostic category is linked with an implied risk of malignancy; thus, clinicians may decide on patient management and eventually reduce unnecessary interventional diagnostic procedures. Diagn. Cytopathol. 2016;44:888-901. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Identifying a need for more focused treatment of chlamydia and gonorrhoea in the emergency department.

PubMed

Wilson, Sean P; Knych, McKenna; Iordanova, Rossitza; Mahan, Meredith; Vohra, Taher

2016-10-01

The indolent nature of chlamydia and gonorrhoea, along with the time delay associated with current diagnostic testing, makes definitive diagnosis while in the emergency department impossible. We therefore sought to determine the proportion of patients who receive accurate, presumptive antimicrobial treatment for these infections. A retrospective chart review was performed on all patient encounters that underwent chlamydia and gonorrhoea testing at an urban emergency department during a single month in 2012. Each encounter was reviewed for nucleic acid amplification test results and whether presumptive antibiotics were given during the initial visit. A total of 639 patient encounters were reviewed; 87.2% were female and the mean age was 26.7 years. Chlamydia was present in 11.1%, with women and men having similar infection rates: 10.6% vs. 14.6% (p = 0.277). Gonorrhoea was present in 5.0%, with a lower prevalence among women than men: 3.2% vs. 17.1% (p < 0.001). Women received presumptive treatment less often than men: 37.7% vs. 82.9% (p < 0.001). Presumptive treatment was less accurate in women than men: 7.9% vs. 25.6% (p < 0.001). After combining genders, 10.2% received accurate presumptive treatment; 33.3% were overtreated and 4.4% missed treatment. Presumptive treatment for chlamydia and gonorrhoea was more frequent and more accurate in men than in women. Overall, one-third of patients received unnecessary antibiotics, yet nearly 5% missed treatment. Better methods are needed for identifying patients who need treatment. © The Author(s) 2016.

An echo to Choosing Wisely® in Switzerland

PubMed Central

Chok, Lionel; Debrunner, Johann; Jaeggli, Sandra; Kusic, Karmen; Bachli, Esther B

2018-01-01

Background Inspired by the US Choosing Wisely®, in 2016 the Swiss Society of General Internal Medicine released a list of five treatments or diagnostic tests used in the hospital and considered unnecessary based on not improving patient care and adding to health care costs. These “Smarter Medicine” recommendations were implemented in the Department of Internal Medicine, Uster Hospital, in August 2016. They were supported by lectures and weekly email communications. We analyzed the number of blood draws before and after implementation of the recommendation aimed at reducing blood tests. Methods This retrospective analysis was conducted in the Department of Internal Medicine, Uster Hospital, Canton of Zurich, Switzerland. Patients hospitalized in the 3 months before and after implementation were analyzed. Results A total of 2023 hospitalizations were analyzed. There was a significant decrease in the number of blood draws after introduction of the recommendation: before implementation, the median number of blood draws per patient was 4 (interquartile range [IQR], 2–7); after implementation, the median was 4 (IQR, 2–6; P = 0.002). Indeed, since 46% of the patients in the first group had more than four blood tests, this ratio decreased to 39% after implementation. Discussion Inappropriate blood draws may lead to anemia, patient discomfort and false-positive results. The simple and low-cost interventions used to implement “Smarter Medicine” have changed physician behavior by reducing the number of blood orders. These results are promising. Whether such recommendations will impact patient and clinical outcomes remains unknown; hence, further studies are needed to clarify this issue. PMID:29765244

75 FR 8375 - Device Improvements to Reduce Unnecessary Radiation Exposure From Medical Imaging; Public Meeting...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-24

... radiologic technologists or technologists in other specialties as well as physicians in all medical...] Device Improvements to Reduce Unnecessary Radiation Exposure From Medical Imaging; Public Meeting... Improvements to Reduce Unnecessary Radiation Exposure From Medical Imaging.'' The purpose of this meeting is to...

33 CFR 117.11 - Unnecessary opening of the draw.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 33 Navigation and Navigable Waters 1 2010-07-01 2010-07-01 false Unnecessary opening of the draw. 117.11 Section 117.11 Navigation and Navigable Waters COAST GUARD, DEPARTMENT OF HOMELAND SECURITY BRIDGES DRAWBRIDGE OPERATION REGULATIONS General Requirements § 117.11 Unnecessary opening of the draw. No...

10 CFR 26.105 - Preparing for urine collection.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 10 Energy 1 2012-01-01 2012-01-01 false Preparing for urine collection. 26.105 Section 26.105 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Collecting Specimens for Testing § 26.105 Preparing for urine collection. (a) The collector shall ask the donor to remove any unnecessary outer...

10 CFR 26.105 - Preparing for urine collection.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 10 Energy 1 2014-01-01 2014-01-01 false Preparing for urine collection. 26.105 Section 26.105 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Collecting Specimens for Testing § 26.105 Preparing for urine collection. (a) The collector shall ask the donor to remove any unnecessary outer...

10 CFR 26.105 - Preparing for urine collection.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 10 Energy 1 2013-01-01 2013-01-01 false Preparing for urine collection. 26.105 Section 26.105 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Collecting Specimens for Testing § 26.105 Preparing for urine collection. (a) The collector shall ask the donor to remove any unnecessary outer...

10 CFR 26.105 - Preparing for urine collection.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 10 Energy 1 2010-01-01 2010-01-01 false Preparing for urine collection. 26.105 Section 26.105 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Collecting Specimens for Testing § 26.105 Preparing for urine collection. (a) The collector shall ask the donor to remove any unnecessary outer...

10 CFR 26.105 - Preparing for urine collection.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 10 Energy 1 2011-01-01 2011-01-01 false Preparing for urine collection. 26.105 Section 26.105 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Collecting Specimens for Testing § 26.105 Preparing for urine collection. (a) The collector shall ask the donor to remove any unnecessary outer...

Development of Technologies for Early Detection and Stratification of Breast Cancer

DTIC Science & Technology

2015-10-01

fatal disease progression, or in the cases of over-treatment, unnecessary physical and emotional trauma.4 ELISA, the most common immunoassay for...laboratory to discover new biomarkers that meet these requirements within serum so that a simple blood test can be implemented. We are also working to...microspheres and tested first on standard samples. Assay performance characteristics will be determined to ascertain that they will address

42 CFR 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Procedural Terminology published by the American Medical Association. (vii) Diagnostic tests performed by a... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Medical and Other Health Services § 410.32 Diagnostic x-ray tests, diagnostic laboratory...

42 CFR 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Procedural Terminology published by the American Medical Association. (vii) Diagnostic tests performed by a... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Medical and Other Health Services § 410.32 Diagnostic x-ray tests, diagnostic laboratory...

Determining the optimal approach to identifying individuals with chronic obstructive pulmonary disease: The DOC study.

PubMed

Ronaldson, Sarah J; Dyson, Lisa; Clark, Laura; Hewitt, Catherine E; Torgerson, David J; Cooper, Brendan G; Kearney, Matt; Laughey, William; Raghunath, Raghu; Steele, Lisa; Rhodes, Rebecca; Adamson, Joy

2018-06-01

Early identification of chronic obstructive pulmonary disease (COPD) results in patients receiving appropriate management for their condition at an earlier stage in their disease. The determining the optimal approach to identifying individuals with chronic obstructive pulmonary disease (DOC) study was a case-finding study to enhance early identification of COPD in primary care, which evaluated the diagnostic accuracy of a series of simple lung function tests and symptom-based case-finding questionnaires. Current smokers aged 35 or more were invited to undertake a series of case-finding tools, which comprised lung function tests (specifically, spirometry, microspirometry, peak flow meter, and WheezoMeter) and several case-finding questionnaires. The effectiveness of these tests, individually or in combination, to identify small airways obstruction was evaluated against the gold standard of spirometry, with the quality of spirometry tests assessed by independent overreaders. The study was conducted with general practices in the Yorkshire and Humberside area, in the UK. Six hundred eighty-one individuals met the inclusion criteria, with 444 participants completing their study appointments. A total of 216 (49%) with good-quality spirometry readings were included in the analysis. The most effective case-finding tools were found to be the peak flow meter alone, the peak flow meter plus WheezoMeter, and microspirometry alone. In addition to the main analysis, where the severity of airflow obstruction was based on fixed ratios and percent of predicted values, sensitivity analyses were conducted by using lower limit of normal values. This research informs the choice of test for COPD identification; case-finding by use of the peak flow meter or microspirometer could be used routinely in primary care for suspected COPD patients. Only those testing positive to these tests would move on to full spirometry, thereby reducing unnecessary spirometric testing. © 2018 John Wiley & Sons, Ltd.

The business case for payer support of a community-based health information exchange: a humana pilot evaluating its effectiveness in cost control for plan members seeking emergency department care.

PubMed

Tzeel, Albert; Lawnicki, Victor; Pemble, Kim R

2011-07-01

As emergency department utilization continues to increase, health plans must limit their cost exposure, which may be driven by duplicate testing and a lack of medical history at the point of care. Based on previous studies, health information exchanges (HIEs) can potentially provide health plans with the ability to address this need. To assess the effectiveness of a community-based HIE in controlling plan costs arising from emergency department care for a health plan's members. Albert Tzeel. The study design was observational, with an eligible population (N = 1482) of fully insured plan members who sought emergency department care on at least 2 occasions during the study period, from December 2008 through March 2010. Cost and utilization data, obtained from member claims, were matched to a list of persons utilizing the emergency department where HIE querying could have occurred. Eligible members underwent propensity score matching to create a test group (N = 326) in which the HIE database was queried in all emergency department visits, and a control group (N = 325) in which the HIE database was not queried in any emergency department visit. Post-propensity matching analysis showed that the test group achieved an average savings of $29 per emergency department visit compared with the control group. Decreased utilization of imaging procedures and diagnostic tests drove this cost-savings. When clinicians utilize HIE in the care of patients who present to the emergency department, the costs borne by a health plan providing coverage for these patients decrease. Although many factors can play a role in this finding, it is likely that HIEs obviate unnecessary service utilization through provision of historical medical information regarding specific patients at the point of care.

Contribution of a Comparative Western Blot Method to Early Postnatal Diagnosis of Congenital Syphilis.

PubMed

Marangoni, Antonella; Foschi, Claudio; Capretti, Maria Grazia; Nardini, Paola; Compri, Monica; Corvaglia, Luigi Tommaso; Faldella, Giacomo; Cevenini, Roberto

2016-05-01

Serology has a pivotal role in the diagnosis of congenital syphilis (CS), but problems arise because of the passive transfer of IgG antibodies across the placenta. The aim of this study was to assess the diagnostic value of a comparative Western blot (WB) method finalized to match the IgG immunological profiles of mothers and their own babies at birth in order to differentiate between passively transmitted maternal antibodies and antibodies synthesized by the infants against Treponema pallidum Thirty infants born to mothers with unknown or inadequate treatment for syphilis were entered in a retrospective study, conducted at St. Orsola-Malpighi Hospital, Bologna, Italy. All of the infants underwent clinical, instrumental, and laboratory examinations, including IgM WB testing. For the retrospective study, an IgG WB assay was performed by blotting T. pallidum antigens onto nitrocellulose sheets and incubating the strips with serum specimens from mother-child pairs. CS was diagnosed in 11 out of the 30 enrolled infants; 9/11 cases received the definitive diagnosis within the first week of life, whereas the remaining two were diagnosed later because of increasing serological test titers. The use of the comparative IgG WB testing performed with serum samples from mother-child pairs allowed a correct CS diagnosis in 10/11 cases. The CS diagnosis was improved by a strategy combining comparative IgG WB results with IgM WB results, leading to a sensitivity of 100%. The comparative IgG WB test is thus a welcome addition to the conventional laboratory methods used for CS diagnosis, allowing identification and adequate treatment of infected infants and avoiding unnecessary therapy of uninfected newborns. Copyright © 2016, American Society for Microbiology. All Rights Reserved.

Validation of STA-Liatest D-Di assay for exclusion of pulmonary embolism according to the latest Clinical and Laboratory Standard Institute/Food and Drug Administration guideline. Results of a multicenter management study.

PubMed

Pernod, Gilles; Wu, Haifeng; de Maistre, Emmanuel; Lazarchick, John; Kassis, Jeannine; Aguilar, Carlos; Vera, Pascual M; Palareti, Gualtiero; D'Angelo, Armando

2017-04-01

: Combined clinical pretest probability (PTP) and D-dimer testing have great diagnostic value for pulmonary embolism exclusion. To harmonize performance levels of D-dimer assays available on the market, the Clinical and Laboratory Standard Institute (CLSI) has published a guideline, endorsed by the US Food and Drug Administration (FDA). Such guideline specifies the ideal D-dimer assay characteristic and target population. This study was conducted following the CLSI guideline to upgrade the assay-intended use and obtain FDA clearance of STA-Liatest D-Di assay for pulmonary embolism exclusion in patient with low/moderate PTP. This was an international, multicenter, prospective nonrandomized, noninterventional clinical outcome management study conducted in a standard of care setting. D-dimer assay was performed in consecutive, ambulatory outpatients suspected of pulmonary embolism, with low/moderate PTP, and without medical conditions or in clinical settings known to alter default D-dimer values regardless of the presence of thrombosis using a threshold of 0.5 μg/ml (fibrinogen equivalent units) for venous thromboembolism exclusion. Results were used to determine test performance. Of 1141 patients who underwent D-dimer testing, 1060 had valid results and completed study as planned. STA-Liatest D-Di assay performance has exceeded the CLSI/FDA guidance requirements, with a sensitivity of 97.6% (95% confidence interval: 91.7-99.7%) and a negative predictive value of 99.7% (95% confidence interval: 99.0-100%). STA-Liatest D-Di assay has an excellent performance when used in combination with a PTP score in relevant patients and has the potential to minimize the economic healthcare burden avoiding unnecessary and expensive imaging tests.

Urinary MicroRNAs of Prostate Cancer: Virus-Encoded hsv1-miRH18 and hsv2-miR-H9-5p Could Be Valuable Diagnostic Markers.

PubMed

Yun, Seok Joong; Jeong, Pildu; Kang, Ho Won; Kim, Ye-Hwan; Kim, Eun-Ah; Yan, Chunri; Choi, Young-Ki; Kim, Dongho; Kim, Jung Min; Kim, Seon-Kyu; Kim, Seon-Young; Kim, Sang Tae; Kim, Won Tae; Lee, Ok-Jun; Koh, Gou-Young; Moon, Sung-Kwon; Kim, Isaac Yi; Kim, Jayoung; Choi, Yung-Hyun; Kim, Wun-Jae

2015-06-01

MicroRNAs (miRNAs) in biological fluids are potential biomarkers for the diagnosis and assessment of urological diseases such as benign prostatic hyperplasia (BPH) and prostate cancer (PCa). The aim of the study was to identify and validate urinary cell-free miRNAs that can segregate patients with PCa from those with BPH. In total, 1,052 urine, 150 serum, and 150 prostate tissue samples from patients with PCa or BPH were used in the study. A urine-based miRNA microarray analysis suggested the presence of differentially expressed urinary miRNAs in patients with PCa, and these were further validated in three independent PCa cohorts, using a quantitative reverse transcriptionpolymerase chain reaction analysis. The expression levels of hsa-miR-615-3p, hsv1-miR-H18, hsv2-miR-H9-5p, and hsa-miR-4316 were significantly higher in urine samples of patients with PCa than in those of BPH controls. In particular, herpes simplex virus (hsv)-derived hsv1-miR-H18 and hsv2-miR-H9-5p showed better diagnostic performance than did the serum prostate-specific antigen (PSA) test for patients in the PSA gray zone. Furthermore, a combination of urinary hsv2-miR-H9-5p with serum PSA showed high sensitivity and specificity, providing a potential clinical benefit by reducing unnecessary biopsies. Our findings showed that hsv-encoded hsv1-miR-H18 and hsv2-miR-H9-5p are significantly associated with PCa and can facilitate early diagnosis of PCa for patients within the serum PSA gray zone.

Urinary MicroRNAs of Prostate Cancer: Virus-Encoded hsv1-miRH18 and hsv2-miR-H9-5p Could Be Valuable Diagnostic Markers

PubMed Central

Yun, Seok Joong; Jeong, Pildu; Kang, Ho Won; Kim, Ye-Hwan; Kim, Eun-Ah; Yan, Chunri; Choi, Young-Ki; Kim, Dongho; Kim, Jung Min; Kim, Seon-Kyu; Kim, Seon-Young; Kim, Sang Tae; Kim, Won Tae; Lee, Ok-Jun; Koh, Gou-Young; Moon, Sung-Kwon; Kim, Isaac Yi; Kim, Jayoung; Choi, Yung-Hyun; Kim, Wun-Jae

2015-01-01

Purpose: MicroRNAs (miRNAs) in biological fluids are potential biomarkers for the diagnosis and assessment of urological diseases such as benign prostatic hyperplasia (BPH) and prostate cancer (PCa). The aim of the study was to identify and validate urinary cell-free miRNAs that can segregate patients with PCa from those with BPH. Methods: In total, 1,052 urine, 150 serum, and 150 prostate tissue samples from patients with PCa or BPH were used in the study. A urine-based miRNA microarray analysis suggested the presence of differentially expressed urinary miRNAs in patients with PCa, and these were further validated in three independent PCa cohorts, using a quantitative reverse transcriptionpolymerase chain reaction analysis. Results: The expression levels of hsa-miR-615-3p, hsv1-miR-H18, hsv2-miR-H9-5p, and hsa-miR-4316 were significantly higher in urine samples of patients with PCa than in those of BPH controls. In particular, herpes simplex virus (hsv)-derived hsv1-miR-H18 and hsv2-miR-H9-5p showed better diagnostic performance than did the serum prostate-specific antigen (PSA) test for patients in the PSA gray zone. Furthermore, a combination of urinary hsv2-miR-H9-5p with serum PSA showed high sensitivity and specificity, providing a potential clinical benefit by reducing unnecessary biopsies. Conclusions: Our findings showed that hsv-encoded hsv1-miR-H18 and hsv2-miR-H9-5p are significantly associated with PCa and can facilitate early diagnosis of PCa for patients within the serum PSA gray zone. PMID:26126436

Added value of Virtual Touch IQ shear wave elastography in the ultrasound assessment of breast lesions.

PubMed

Ianculescu, Victor; Ciolovan, Laura Maria; Dunant, Ariane; Vielh, Philippe; Mazouni, Chafika; Delaloge, Suzette; Dromain, Clarisse; Blidaru, Alexandru; Balleyguier, Corinne

2014-05-01

To determine the diagnostic performance of Acoustic Radiation Force Impulse (ARFI) Virtual Touch IQ shear wave elastography in the discrimination of benign and malignant breast lesions. Conventional B-mode and elasticity imaging were used to evaluate 110 breast lesions. Elastographic assessment of breast tissue abnormalities was done using a shear wave based technique, Virtual Touch IQ (VTIQ), implemented on a Siemens Acuson S3000 ultrasound machine. Tissue mechanical properties were interpreted as two-dimensional qualitative and quantitative colour maps displaying relative shear wave velocity. Wave speed measurements in m/s were possible at operator defined regions of interest. The pathologic diagnosis was established on samples obtained by ultrasound guided core biopsy or fine needle aspiration. BIRADS based B-mode evaluation of the 48 benign and 62 malignant lesions achieved 92% sensitivity and 62.5% specificity. Subsequently performed VTIQ elastography relying on visual interpretation of the colour overlay displaying relative shear wave velocities managed similar standalone diagnostic performance with 92% sensitivity and 64.6% specificity. Lesion and surrounding tissue shear wave speed values were calculated and a significant difference was found between the benign and malignant populations (Mann-Whitney U test, p<0.0001). By selecting a lesion cut-off value of 3.31m/s we achieved 80.4% sensitivity and 73% specificity. Applying this threshold only to BIRADS 4a masses, we reached overall levels of 92% sensitivity and 72.9% specificity. VTIQ qualitative and quantitative elastography has the potential to further characterise B-mode detected breast lesions, increasing specificity and reducing the number of unnecessary biopsies. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Gastrointestinal manifestations of cow's milk allergy.

PubMed

Magazzù, Giuseppe; Scoglio, Riccardo

2002-12-01

To review and discuss the relationship between cow's milk allergy (CMA) and some gastrointestinal manifestations, such as gastroesophageal reflux, constipation, food protein-induced enterocolitis, and food-induced eosinophilic proctocolitis, with respect to diagnostic strategies that might eliminate the need for a double-blind, placebo-controlled oral food challenge (DBPCFC). A review of pertinent PubMed articles, published during the past 10 years, was performed. To obtain positive and negative predictive values known as posterior probabilities and to calculate the likelihood ratio, only those studies including both patients and control subjects were selected for analysis. With respect to gastroesophageal reflux, a typical 24-hour esophageal pH monitoring pattern might obviate the performance of a DBPCFC in patients with symptoms of reflux suspected of having CMA, provided this pH pattern is confirmed in other studies. A relationship between CMA and constipation has been reported in only one prospective controlled study; the clinical and laboratory variables of perianal lesions, histologic abnormalities, and signs of hypersensitivity had likelihood ratios of 2.2, 2.4, and 3.7, respectively, and posttest probabilities of 83, 84, and 88%, respectively. Therefore, a DBPCFC is warranted. In reference to food protein-induced enterocolitis, clinical and laboratory criteria suggested in the literature for defining a food challenge as positive have not been prospectively evaluated in the untreated state. Some simple stool tests, such as fecal tumor necrosis factor-alpha and alpha1-antitrypsin determination, might be candidates for diagnostic studies in patients with food protein-induced enterocolitis, if prospectively evaluated. In infants with food-induced eosinophilic proctocolitis, rectal biopsy invariably shows eosinophilic infiltration and thus makes performance of a DBPCFC unnecessary. Although the current diagnosis of gastrointestinal manifestations of CMA usually depends on a DBPCFC, investigators continue to study other options for confirming the diagnosis.

Prevalence of non-influenza respiratory viruses in acute respiratory infection cases in Mexico

PubMed Central

Fernandes-Matano, Larissa; Monroy-Muñoz, Irma Eloísa; Angeles-Martínez, Javier; Sarquiz-Martinez, Brenda; Palomec-Nava, Iliana Donají; Pardavé-Alejandre, Hector Daniel; Santos Coy-Arechavaleta, Andrea; Santacruz-Tinoco, Clara Esperanza; González-Ibarra, Joaquín; González-Bonilla, Cesar Raúl

2017-01-01

Background Acute respiratory infections are the leading cause of morbidity and mortality worldwide. Although a viral aetiological agent is estimated to be involved in up to 80% of cases, the majority of these agents have never been specifically identified. Since 2009, diagnostic and surveillance efforts for influenza virus have been applied worldwide. However, insufficient epidemiological information is available for the many other respiratory viruses that can cause Acute respiratory infections. Methods This study evaluated the presence of 14 non-influenza respiratory viruses in 872 pharyngeal exudate samples using RT-qPCR. All samples met the operational definition of a probable case of an influenza-like illness or severe acute respiratory infection and had a previous negative result for influenza by RT-qPCR. Results The presence of at least one non-influenza virus was observed in 312 samples (35.8%). The most frequent viruses were rhinovirus (RV; 33.0%), human respiratory syncytial virus (HRSV; 30.8%) and human metapneumovirus (HMPV; 10.6%). A total of 56 cases of co-infection (17.9%) caused by 2, 3, or 4 viruses were identified. Approximately 62.5% of all positive cases were in children under 9 years of age. Conclusion In this study, we identified 13 non-influenza respiratory viruses that could occur in any season of the year. This study provides evidence for the prevalence and seasonality of a wide range of respiratory viruses that circulate in Mexico and constitute a risk for the population. Additionally, our data suggest that including these tests more widely in the diagnostic algorithm for influenza may reduce the use of unnecessary antibiotics, reduce the hospitalisation time, and enrich national epidemiological data with respect to the infections caused by these viruses. PMID:28467515

Easily obtainable clinical features increase the diagnostic accuracy for latent autoimmune diabetes in adults: an evidence-based report.

PubMed

Lutgens, Maurice W M D; Meijer, Melanie; Peeters, Babette; Poulsen, Marie-Louise N F; Rutten, Marjet J; Bots, Michiel L; van der Heijden, Geert J M G; Soedamah-Muthu, Sabita S

2008-12-01

Latent autoimmune diabetes in adults (LADA) represents a subgroup of diabetes mellitus. LADA is characterised by adult-onset diabetes and circulating autoimmune antibodies. LADA patients may need a different therapeutic approach than the usual type 2 diabetes mellitus. When LADA is inadequately diagnosed as type 2 diabetes mellitus, LADA patients will mistakenly be exposed to a high dose of oral glucose lowering drugs and their possible side effects. To assess which clinical features predict the presence or absence of LADA in patients older than 25 years presenting with hyperglycemia. A structured Medline and Embase search was conducted. Titles and abstracts were screened using predetermined selection criteria. Critical appraisal was based on standardized validity criteria for diagnostic research. One-hundred and eighty-four papers were retrieved of which after assessment of relevance and validity 2 studies remained for further analysis. One study reported a probability of LADA of 0.99 with one or two out of the following five clinical features: age at onset <50 years; acute symptoms; BMI<25 kg/m(2); a history of autoimmune disease; a family history positive for diabetes mellitus. The other study reported a probability of LADA of zero with none of the following clinical features and of 0.32 with one out of three: fasting blood glucose> or =15 mmol/l and/or HbA(1c)> or =10%; 10% reduction in body weight in the previous 3 months; BMI<25 kg/m(2). Further testing for LADA by measurement of autoimmune antibodies appears to be unnecessary in the absence of a specific set of clinical features. Before initiating therapy applying the above criteria may help to separate LADA from usual type 2 diabetes.

Principles, practices and knowledge of clinicians when assessing febrile children: a qualitative study in Kenya.

PubMed

Hooft, Anneka M; Ripp, Kelsey; Ndenga, Bryson; Mutuku, Francis; Vu, David; Baltzell, Kimberly; Masese, Linnet N; Vulule, John; Mukoko, Dunstan; LaBeaud, A Desiree

2017-09-20

Clinicians in low resource settings in malaria endemic regions face many challenges in diagnosing and treating febrile illnesses in children. Given the change in WHO guidelines in 2010 that recommend malaria testing prior to treatment, clinicians are now required to expand the differential when malaria testing is negative. Prior studies have indicated that resource availability, need for additional training in differentiating non-malarial illnesses, and lack of understanding within the community of when to seek care play a role in effective diagnosis and treatment. The objective of this study was to examine the various factors that influence clinician behavior in diagnosing and managing children presenting with fever to health centres in Kenya. A total of 20 clinicians (2 paediatricians, 1 medical officer, 2 nurses, and 15 clinical officers) were interviewed, working at 5 different government-sponsored public clinic sites in two areas of Kenya where malaria is prevalent. Clinicians were interviewed one-on-one using a structured interview technique. Interviews were then analysed qualitatively for themes. The following five themes were identified: (1) Strong familiarity with diagnosis of malaria and testing for malaria; (2) Clinician concerns about community understanding of febrile illness, use of traditional medicine, delay in seeking care, and compliance; (3) Reliance on clinical guidelines, history, and physical examination to diagnose febrile illness and recognize danger signs; (4) Clinician discomfort with diagnosis of primary viral illness leading to increased use of empiric antibiotics; and (5) Lack of resources including diagnostic testing, necessary medications, and training modalities contributes to the difficulty clinicians face in assessing and treating febrile illness in children. These themes persisted across all sites, despite variation in levels of medical care. Within these themes, clinicians consistently expressed a need for reliable basic testing, especially haemograms and bacterial cultures. Clinicians discussed the use of counseling and education to improve community understanding of febrile illness in order to decrease preventable deaths in children. Results of this study suggest that since malarial testing has become more widespread, clinicians working in resource-poor environments still face difficulty when evaluating a child with fever, especially when malaria testing is negative. Improving access to additional diagnostics, continuing medical education, and ongoing evaluation and revision of clinical guidelines may lead to more consistent management of febrile illness by providers, and may potentially decrease prescription of unnecessary antibiotics. Additional interventions at the community level may also have an important role in managing febrile illness, however, more studies are needed to identify targets for intervention at both the clinic and community levels.

Impact of Laboratory Test Use Strategies in a Turkish Hospital

PubMed Central

Yılmaz, Fatma Meriç; Kahveci, Rabia; Aksoy, Altan; Özer Kucuk, Emine; Akın, Tezcan; Mathew, Joseph Lazar; Meads, Catherine; Zengin, Nurullah

2016-01-01

Objectives Eliminating unnecessary laboratory tests is a good way to reduce costs while maintain patient safety. The aim of this study was to define and process strategies to rationalize laboratory use in Ankara Numune Training and Research Hospital (ANH) and calculate potential savings in costs. Methods A collaborative plan was defined by hospital managers; joint meetings with ANHTA and laboratory professors were set; the joint committee invited relevant staff for input, and a laboratory efficiency committee was created. Literature was reviewed systematically to identify strategies used to improve laboratory efficiency. Strategies that would be applicable in local settings were identified for implementation, processed, and the impact on clinical use and costs assessed for 12 months. Results Laboratory use in ANH differed enormously among clinics. Major use was identified in internal medicine. The mean number of tests per patient was 15.8. Unnecessary testing for chloride, folic acid, free prostate specific antigen, hepatitis and HIV testing were observed. Test panel use was pinpointed as the main cause of overuse of the laboratory and the Hospital Information System test ordering page was reorganized. A significant decrease (between 12.6–85.0%) was observed for the tests that were taken to an alternative page on the computer screen. The one year study saving was equivalent to 371,183 US dollars. Conclusion Hospital-based committees including laboratory professionals and clinicians can define hospital based problems and led to a standardized approach to test use that can help clinicians reduce laboratory costs through appropriate use of laboratory tests. PMID:27077653

Strategies to reduce inappropriate laboratory blood test orders in intensive care are effective and safe: a before-and-after quality improvement study.

PubMed

Dhanani, J A; Barnett, A G; Lipman, J; Reade, M C

2018-05-01

Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28% reduction in the tests performed in the intervention period (P <0.0001 compared to pre-intervention period) and 26% in the post-intervention period (P <0.0001 compared to pre-intervention period). There were no ICU or hospital mortality differences between the groups. There were no significant haemoglobin differences between the groups. A multimodal intervention safely reduced pathology test ordering in the ICU, resulting in substantial cost savings.

Delay in reviewing test results prolongs hospital length of stay: a retrospective cohort study.

PubMed

Ong, Mei-Sing; Magrabi, Farah; Coiera, Enrico

2018-05-16

Failure in the timely follow-up of test results has been widely documented, contributing to delayed medical care. Yet, the impact of delay in reviewing test results on hospital length of stay (LOS) has not been studied. We examine the relationship between laboratory tests review time and hospital LOS. A retrospective cohort study of inpatients admitted to a metropolitan teaching hospital in Sydney, Australia, between 2011 and 2012 (n = 5804). Generalized linear models were developed to examine the relationship between hospital LOS and cumulative clinician read time (CRT), defined as the time taken by clinicians to review laboratory test results performed during an inpatient stay after they were reported in the computerized test reporting system. The models were adjusted for patients' age, sex, and disease severity (measured by the Charlson Comorbidity index), the number of test panels performed, the number of unreviewed tests pre-discharge, and the cumulative laboratory turnaround time (LTAT) of tests performed during an inpatient stay. Cumulative CRT is significantly associated with prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of prolonged LOS by 13.2% (p < 0.0001). Restricting the analysis to tests with abnormal results strengthened the relationship between cumulative CRT and prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of delayed discharge by 33.6% (p < 0.0001). Increasing age, disease severity and total number of tests were also significantly associated with prolonged LOS. Increasing number of unreviewed tests was negatively associated with prolonged LOS. Reducing unnecessary hospital LOS has become a critical health policy goal as healthcare costs escalate. Preventing delay in reviewing test results represents an important opportunity to address potentially avoidable hospital stays and unnecessary resource utilization.

[Advantages and disadvantages of direct-to-consumer genetic tests].

PubMed

Christiansen, Camilla Worm; Gerdes, Anne-Marie Axø

2017-03-13

Direct-to-consumer genetic tests are sold over the internet to consumers all over the world - including Denmark. No regulation of these tests has been introduced neither in Denmark nor in Europe, even though they have been on the market since 2007. Such tests have several advantages, but indeed also a long list of potential disadvantages, which are most often ignored, and among these is insufficient training of general practitioners in performing the necessary counselling but also the risk of increased expenses to unnecessary follow-up consultations.

Diagnostic value of two commercial chromatographic "patient-side" tests in the diagnosis of acute canine leptospirosis.

PubMed

Gloor, C I; Schweighauser, A; Francey, T; Rodriguez-Campos, S; Vidondo, B; Bigler, B; Schuller, S

2017-03-01

To determine the diagnostic performance of two patient-side tests (RDT-1: Test-it™ and RDT-2 Witness®Lepto) in the early diagnosis of canine leptospirosis. Retrospective study of 108 dogs with leptospirosis and 53 controls. Leptospirosis was diagnosed based on compatible clinical and clinicopathologic signs and either a single microscopic agglutination test titre_ >800 (n=49), seroconversion (n=53), positive urine real time PCR (RT-PCR) (n=1), evidence of spirochaetes in silver-stained tissues (n=1) or a combination of these (n=4). Leptospirosis was excluded in dogs with a convincing alternative diagnosis and single microscopic agglutination testing titres _<200 (n=46) or lack of seroconversion (n=7). Indices of diagnostic accuracy of the rapid diagnostic tests were calculated by comparing admission rapid diagnostic test results to the final disease status. Rapid diagnostic test-1 was performed in 118 dogs, rapid diagnostic test-2 in 69 dogs and both tests in 26 dogs. Weak positive results occurred frequently representing 22·6% (rapid diagnostic test-1) and 32·3% (rapid diagnostic test-2) of all positive tests in dogs with leptospirosis. If weak positive rapid diagnostic tests were considered positive, rapid diagnostic test-1 and rapid diagnostic test-2 had sensitivities of 82 and 76%, specificities of 91 and 100%, positive predictive values of 94% and 100% and negative predictive values of 73% and 74%, respectively. There were some technical problems with rapid diagnostic test-1. The diagnostic performance of the rapid diagnostic tests is similar to that reported for the microscopic agglutination test. Both can support a diagnosis of leptospirosis with high specificity but leptospirosis cannot be excluded based on a negative admission test result. Both RDTs are useful in conjunction with other confirmatory tests. © 2017 British Small Animal Veterinary Association.

A review of eleven cases of tuberculosis presenting as sternal wound abscess after open heart surgery.

PubMed

Tabaja, Hussam; Hajar, Zeina; Kanj, Souha S

2017-10-01

Sternal wound infection with Mycobacterium tuberculosis is an uncommon yet highly challenging disease that can be quite insidious with various presentations. We hereby provide a review of 10 cases in current literature and describe an additional case which illustrates the difficulties associated with diagnosis. We used PubMed and Google search engine to search the literature for all published papers reporting on cases of sternal M. tuberculosis infections post open-heart surgeries. A total of 11 cases were presented, including a case of our own. The majority were males and were exposed to endemic areas. The average age was 59.6 ± 15.5 years. Coronary artery bypass surgery accounted for 73% of procedures and the average time to symptoms onset was 12.2 ± 16.6 months. Diabetes was the most reported non-cardiac comorbidity. Presenting symptoms varied and only 5 patients had other organs involved. Blood tests and radiographic studies were neither sensitive nor specific. M. tuberculosis culture on debrided tissues was the most sensitive test but often forgotten initially. Diagnostic delay was seen in almost all cases, often leading to unnecessary courses of antibiotics and aggressive surgical interventions. Finally, all patients responded well to anti-tuberculosis treatment, with reported treatment duration ranging from 9 to 12 months. M. tuberculosis infection of the sternum should be suspected in late-onset sternal wound infections post open-heart surgery especially when the course is chronic and indolent.

Region of interest processing for iterative reconstruction in x-ray computed tomography

NASA Astrophysics Data System (ADS)

Kopp, Felix K.; Nasirudin, Radin A.; Mei, Kai; Fehringer, Andreas; Pfeiffer, Franz; Rummeny, Ernst J.; Noël, Peter B.

2015-03-01

The recent advancements in the graphics card technology raised the performance of parallel computing and contributed to the introduction of iterative reconstruction methods for x-ray computed tomography in clinical CT scanners. Iterative maximum likelihood (ML) based reconstruction methods are known to reduce image noise and to improve the diagnostic quality of low-dose CT. However, iterative reconstruction of a region of interest (ROI), especially ML based, is challenging. But for some clinical procedures, like cardiac CT, only a ROI is needed for diagnostics. A high-resolution reconstruction of the full field of view (FOV) consumes unnecessary computation effort that results in a slower reconstruction than clinically acceptable. In this work, we present an extension and evaluation of an existing ROI processing algorithm. Especially improvements for the equalization between regions inside and outside of a ROI are proposed. The evaluation was done on data collected from a clinical CT scanner. The performance of the different algorithms is qualitatively and quantitatively assessed. Our solution to the ROI problem provides an increase in signal-to-noise ratio and leads to visually less noise in the final reconstruction. The reconstruction speed of our technique was observed to be comparable with other previous proposed techniques. The development of ROI processing algorithms in combination with iterative reconstruction will provide higher diagnostic quality in the near future.

Development of wide area environment accelerator operation and diagnostics method

NASA Astrophysics Data System (ADS)

Uchiyama, Akito; Furukawa, Kazuro

2015-08-01

Remote operation and diagnostic systems for particle accelerators have been developed for beam operation and maintenance in various situations. Even though fully remote experiments are not necessary, the remote diagnosis and maintenance of the accelerator is required. Considering remote-operation operator interfaces (OPIs), the use of standard protocols such as the hypertext transfer protocol (HTTP) is advantageous, because system-dependent protocols are unnecessary between the remote client and the on-site server. Here, we have developed a client system based on WebSocket, which is a new protocol provided by the Internet Engineering Task Force for Web-based systems, as a next-generation Web-based OPI using the Experimental Physics and Industrial Control System Channel Access protocol. As a result of this implementation, WebSocket-based client systems have become available for remote operation. Also, as regards practical application, the remote operation of an accelerator via a wide area network (WAN) faces a number of challenges, e.g., the accelerator has both experimental device and radiation generator characteristics. Any error in remote control system operation could result in an immediate breakdown. Therefore, we propose the implementation of an operator intervention system for remote accelerator diagnostics and support that can obviate any differences between the local control room and remote locations. Here, remote-operation Web-based OPIs, which resolve security issues, are developed.

Toxocariasis: a silent threat with a progressive public health impact.

PubMed

Chen, Jia; Liu, Quan; Liu, Guo-Hua; Zheng, Wen-Bin; Hong, Sung-Jong; Sugiyama, Hiromu; Zhu, Xing-Quan; Elsheikha, Hany M

2018-06-13

Toxocariasis is a neglected parasitic zoonosis that afflicts millions of the pediatric and adolescent populations worldwide, especially in impoverished communities. This disease is caused by infection with the larvae of Toxocara canis and T. cati, the most ubiquitous intestinal nematode parasite in dogs and cats, respectively. In this article, recent advances in the epidemiology, clinical presentation, diagnosis and pharmacotherapies that have been used in the treatment of toxocariasis are reviewed. Over the past two decades, we have come far in our understanding of the biology and epidemiology of toxocariasis. However, lack of laboratory infrastructure in some countries, lack of uniform case definitions and limited surveillance infrastructure are some of the challenges that hindered the estimation of global disease burden. Toxocariasis encompasses four clinical forms: visceral, ocular, covert and neural. Incorrect or misdiagnosis of any of these disabling conditions can result in severe health consequences and considerable medical care spending. Fortunately, multiple diagnostic modalities are available, which if effectively used together with the administration of appropriate pharmacologic therapies, can minimize any unnecessary patient morbidity. Although progress has been made in the management of toxocariasis patients, there remains much work to be done. Implementation of new technologies and better understanding of the pathogenesis of toxocariasis can identify new diagnostic biomarkers, which may help in increasing diagnostic accuracy. Also, further clinical research breakthroughs are needed to develop better ways to effectively control and prevent this serious disease.

Accuracy of MSCT Coronary Angiography with 64 Row CT Scanner—Facing the Facts

PubMed Central

Wehrschuetz, M.; Wehrschuetz, E.; Schuchlenz, H.; Schaffler, G.

2010-01-01

Improvements in multislice computed tomography (MSCT) angiography of the coronary vessels have enabled the minimally invasive detection of coronary artery stenoses, while quantitative coronary angiography (QCA) is the accepted reference standard for evaluation thereof. Sixteen-slice MSCT showed promising diagnostic accuracy in detecting coronary artery stenoses haemodynamically and the subsequent introduction of 64-slice scanners promised excellent and fast results for coronary artery studies. This prompted us to evaluate the diagnostic accuracy, sensitivity, specificity, and the negative und positive predictive value of 64-slice MSCT in the detection of haemodynamically significant coronary artery stenoses. Thirty-seven consecutive subjects with suspected coronary artery disease were evaluated with MSCT angiography and the results compared with QCA. All vessels were considered for the assessment of significant coronary artery stenosis (diameter reduction ≥ 50%). Thirteen patients (35%) were identified as having significant coronary artery stenoses on QCA with 6.3% (35/555) affected segments. None of the coronary segments were excluded from analysis. Overall sensitivity for classifying stenoses of 64-slice MSCT was 69%, specificity was 92%, positive predictive value was 38% and negative predictive value was 98%. The interobserver variability for detection of significant lesions had a k-value of 0.43. Sixty-four-slice MSCT offers the diagnostic potential to detect coronary artery disease, to quantify haemodynamically significant coronary artery stenoses and to avoid unnecessary invasive coronary artery examinations. PMID:20567636

Diagnostic value of virtual touch tissue imaging quantification for benign and malignant breast lesions with different sizes

PubMed Central

Liu, Hui; Zhao, Li-Xia; Xu, Guang; Yao, Ming-Hua; Zhang, Ai-Hong; Xu, Hui-Xiong; Wu, Rong

2015-01-01

The study was to explore diagnostic value of the virtual touch tissue imaging quantification (VTIQ) in distinguishing benign and malignant breast lesions of variable sizes. We performed conventional ultrasound and VTIQ in 139 breast lesions. The lesions were categorized into three groups according to size (group 1, ≤ 10 mm; group 2, 10-20 mm; and group 3, > 20 mm), and their mean, min, and max shear wave velocities (SWVs) were measured. Diagnoses were confirmed by pathological examination after surgery or needle biopsy. Receiver-operating characteristic curves (ROC) were constructed to determine the optimum cut-off values, calculate the area under curve (AUC), the sensitivity, specificity and accuracy for each velocity. For all groups, the mean, min, and max SWVs of malignant lesions were significantly higher than those of benign lesions (P < 0.05). The cut-off values of mean, min, and max SWVs were not significantly different among the three groups. In addition, the diagnostic performance of mean, min, and max SWV values is analogous, regardless of lesion size. In conclusion, VTIQ is a strong complement to conventional ultrasound, which is a promising method in the differential diagnosis of the breast lesions with different sizes. Further studies validate our results as well as reduce the number of unnecessary biopsies, regardless of size is warranted. PMID:26550234

Hepatic splenosis mimicking liver metastases in a patient with history of childhood immature teratoma

PubMed Central

Trotovsek, Blaz; Skrbinc, Breda

2016-01-01

Abstract Background Hepatic splenosis is rare condition, preceded by splenectomy or spleen trauma, the term refers to nodular implantation of normal splenic tissue in the liver. In patients with history of malignancy in particular, it can be mistaken for metastases and can lead to unnecessary diagnostic procedures or inappropriate treatment. Case report Twenty-two-year old male was treated for immature teratoma linked to undescended right testicle after birth. On regular follow-up examinations no signs of disease relapse or long-term consequences were observed. He was presented with incidental finding of mature cystic teratoma after elective surgery for what appeared to be left-sided inguinal hernia. The tumour was most likely a metastasis of childhood teratoma. Origin within remaining left testicle was not found. Upon further imaging diagnostics, several intrahepatic lesions were revealed. Based on radiologic appearance they were suspicious to be metastases. The patient underwent two ultrasound guided fine-needle aspiration biopsies. Cytologic diagnosis was inconclusive. Histology of laparoscopically obtained tissue disclosed presence of normal splenic tissue and led to diagnosis of hepatic splenosis. Conclusions Though hepatic splenosis is rare, it needs to be included in differential diagnosis of nodular hepatic lesions. Accurate interpretation of those lesions is crucial for appropriate management of the patient. If diagnosis eludes after cytologic diagnostics alone, laparoscopic excision of nodular lesion is warranted before considering more extensive liver resection. PMID:27247554

Hepatic splenosis mimicking liver metastases in a patient with history of childhood immature teratoma.

PubMed

Jereb, Sara; Trotovsek, Blaz; Skrbinc, Breda

2016-06-01

Hepatic splenosis is rare condition, preceded by splenectomy or spleen trauma, the term refers to nodular implantation of normal splenic tissue in the liver. In patients with history of malignancy in particular, it can be mistaken for metastases and can lead to unnecessary diagnostic procedures or inappropriate treatment. Twenty-two-year old male was treated for immature teratoma linked to undescended right testicle after birth. On regular follow-up examinations no signs of disease relapse or long-term consequences were observed. He was presented with incidental finding of mature cystic teratoma after elective surgery for what appeared to be left-sided inguinal hernia. The tumour was most likely a metastasis of childhood teratoma. Origin within remaining left testicle was not found. Upon further imaging diagnostics, several intrahepatic lesions were revealed. Based on radiologic appearance they were suspicious to be metastases. The patient underwent two ultrasound guided fine-needle aspiration biopsies. Cytologic diagnosis was inconclusive. Histology of laparoscopically obtained tissue disclosed presence of normal splenic tissue and led to diagnosis of hepatic splenosis. Though hepatic splenosis is rare, it needs to be included in differential diagnosis of nodular hepatic lesions. Accurate interpretation of those lesions is crucial for appropriate management of the patient. If diagnosis eludes after cytologic diagnostics alone, laparoscopic excision of nodular lesion is warranted before considering more extensive liver resection.

Evidence of a broken healthcare delivery system in korea: unnecessary hospital outpatient utilization among patients with a single chronic disease without complications.

PubMed

Lee, Jin Yong; Jo, Min-Woo; Yoo, Weon-Seob; Kim, Hyun Joo; Eun, Sang Jun

2014-12-01

This study aims to estimate the volume of unnecessarily utilized hospital outpatient services in Korea and quantify the total cost resulting from the inappropriate utilization. The analysis included a sample of 27,320,505 outpatient claims from the 2009 National Inpatient Sample database. Using the Charlson Comorbidity Index (CCI), patients were considered to have received 'unnecessary hospital outpatient utilization' if they had a CCI score of 0 and were concurrently admitted to hospital for treatment of a single chronic disease - hypertension (HTN), diabetes mellitus (DM), or hyperlipidemia (HL) - without complication. Overall, 85% of patients received unnecessary hospital services. Also hospitals were taking away 18.7% of HTN patients, 18.6% of DM and 31.6% of HL from clinics. Healthcare expenditures from unnecessary hospital outpatient utilization were estimated at: HTN (94,058 thousands USD, 38.6% of total expenditure); DM (17,795 thousands USD, 40.6%) and HL (62,876 thousands USD, 49.1%). If 100% of patients who received unnecessary hospital outpatient services were redirected to clinics, the estimated savings would be 104,226 thousands USD. This research proves that approximately 85% of hospital outpatient utilizations are unnecessary and that a significant amount of money is wasted on unnecessary healthcare services; thus burdening the National Health Insurance Service (NHIS) and patients.

Potential for Pharmacy-Public Health Collaborations Using Pharmacy-Based Point-of-Care Testing Services for Infectious Diseases.

PubMed

Gubbins, Paul O; Klepser, Michael E; Adams, Alex J; Jacobs, David M; Percival, Kelly M; Tallman, Gregory B

Health care professionals must continually identify collaborative ways to combat antibiotic resistance while improving community health and health care delivery. Clinical Laboratory Improvement Amendments of 1988 (CLIA)-waived point-of-care (POC) testing (POCT) services for infectious disease conducted in community pharmacies provide a means for pharmacists to collaborate with prescribers and/or public health officials combating antibiotic resistance while improving community health and health care delivery. To provide a comprehensive literature review that explores the potential for pharmacists to collaborate with public health professionals and prescribers using pharmacy-based CLIA-waived POCT services for infectious diseases. Comprehensive literature review. PubMed and Google Scholar were searched for manuscripts and meeting abstracts for the following key words: infectious disease, community pharmacy, rapid diagnostic tests, rapid assay, and POC tests. All relevant manuscripts and meeting abstracts utilizing POCT in community pharmacies for infectious disease were reviewed. Information regarding the most contemporary evidence regarding CLIA-waived POC infectious diseases tests for infectious diseases and their use in community pharmacies was synthesized to highlight and identify opportunities to develop future collaborations using community pharmacy-based models for such services. Evidence demonstrates that pharmacists in collaboration with other health care professionals can leverage their knowledge and accessibility to provide CLIA-waived POCT services for infectious diseases. Testing for influenza may augment health departments' surveillance efforts, help promote rationale antiviral use, and avoid unnecessary antimicrobial therapy. Services for human immunodeficiency virus infection raise infection status awareness, increase access to health care, and facilitate linkage to appropriate care. Testing for group A streptococcal pharyngitis may curb inappropriate outpatient antibiotic prescribing. However, variance in pharmacy practice statues and the application of CLIA across states stifle collaboration. CLIA-waived POCT services for infectious diseases are a means for pharmacists, public health professionals, and prescribers to collaboratively combat antibiotic resistance and improve community health.

Revolutionizing Clinical Microbiology Laboratory Organization in Hospitals with In Situ Point-of-Care

PubMed Central

Cohen-Bacrie, Stéphan; Ninove, Laetitia; Nougairède, Antoine; Charrel, Rémi; Richet, Hervé; Minodier, Philippe; Badiaga, Sékéné; Noël, Guilhem; La Scola, Bernard; de Lamballerie, Xavier; Drancourt, Michel; Raoult, Didier

2011-01-01

Background Clinical microbiology may direct decisions regarding hospitalization, isolation and anti-infective therapy, but it is not effective at the time of early care. Point-of-care (POC) tests have been developed for this purpose. Methods and Findings One pilot POC-lab was located close to the core laboratory and emergency ward to test the proof of concept. A second POC-lab was located inside the emergency ward of a distant hospital without a microbiology laboratory. Twenty-three molecular and immuno-detection tests, which were technically undemanding, were progressively implemented, with results obtained in less than four hours. From 2008 to 2010, 51,179 tests yielded 6,244 diagnoses. The second POC-lab detected contagious pathogens in 982 patients who benefited from targeted isolation measures, including those undertaken during the influenza outbreak. POC tests prevented unnecessary treatment of patients with non-streptococcal tonsillitis (n = 1,844) and pregnant women negative for Streptococcus agalactiae carriage (n = 763). The cerebrospinal fluid culture remained sterile in 50% of the 49 patients with bacterial meningitis, therefore antibiotic treatment was guided by the molecular tests performed in the POC-labs. With regard to enterovirus meningitis, the mean length-of-stay of infected patients over 15 years old significantly decreased from 2008 to 2010 compared with 2005 when the POC was not in place (1.43±1.09 versus 2.91±2.31 days; p = 0.0009). Altogether, patients who received POC tests were immediately discharged nearly thrice as often as patients who underwent a conventional diagnostic procedure. Conclusions The on-site POC-lab met physicians' needs and influenced the management of 8% of the patients that presented to emergency wards. This strategy might represent a major evolution of decision-making regarding the management of infectious diseases and patient care. PMID:21811599

Pseudomonas Endocarditis with an unstable phenotype: the challenges of isolate characterization and Carbapenem stewardship with a partial review of the literature.

PubMed

Lesho, Emil; Snesrud, Erik; Kwak, Yoon; Ong, Ana; Maybank, Rosslyn; Laguio-Vila, Maryrose; Falsey, Ann R; Hinkle, Mary

2017-01-01

Pseudomonas endocarditis is exceedingly rare, especially in patients without predisposing risks. We present such a case that included unexpected switches in antibacterial resistance profiles in two Pseudomonas aeruginosa (PA) strains with the same whole-genome sequence. The case also involved diagnostic and treatment challenges, such as issues with automated testing platforms, choosing the optimal aminoglycoside, minimizing unnecessary carbapenem exposure, and the need for faster, more informative laboratory tests. On hospital day one (HD-1) a cefepime and piperacillin-tazobactam (FEP-TZP)-susceptible P. aeruginosa was isolated from the bloodstream of a 62-year-old man admitted for evaluation of possible endocarditis and treated with gentamicin and cefepime. On HD-2, his antibiotic regimen was changed to tobramycin and cefepime. On HD-11, he underwent aortic valve replacement, and P. aeruginosa was isolated from the explanted valve. Unexpectedly, it was FEP-TZP-resistant, so cefepime was switched to meropenem. On HD-14, in preparation for whole-genome sequencing (WGS), valve and blood isolates were removed from cryo-storage, re-cultured, and simultaneously tested with the same platforms, reagents, and inoculations previously used. Curiously, the valve isolate was now FEP-TZP-susceptible. WGS revealed that both isolates were phylogenetically identical, differing by a single nucleotide in a chemotaxis-encoding gene. They also contained the same resistance genes ( bla ADC35 , aph(3')-II , bla OXA-50 , catB7 , fosA). Repeated testing on alternate platforms and WGS did not definitively determine the resistance mechanism(s), which in this case, is most likely unstable de-repression of a chromosomal AmpC β-lactamase, porin alterations, or efflux upregulation, with reversion to baseline (non-efflux) transcription. Although sub-culture on specialized media to select for less fit (more resistant) colonies, followed by transcriptome analysis, and multiple sequence alignment, might have revealed the mechanism and better informed the optimal choice of β-lactam, such approaches are neither rapid, nor feasible for hospital laboratories. In this era of escalating drug resistance and dwindling antibiotics, use of the most potent anti-pseudomonals must be balanced with stewardship. Clinicians need access to validated genomic correlates of resistance, and faster, more informative diagnostics. Therefore, we placed these isolates and their sequences in the public domain for inclusion in the Pseudomonas pan-genome and database projects for further countermeasure development.

40 CFR 85.2223 - On-board diagnostic test report.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 40 Protection of Environment 18 2010-07-01 2010-07-01 false On-board diagnostic test report. 85... Tests § 85.2223 On-board diagnostic test report. (a) Motorists whose vehicles fail the on-board diagnostic test described in § 85.2222 shall be provided with the on-board diagnostic test results, including...

40 CFR 85.2223 - On-board diagnostic test report.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 40 Protection of Environment 18 2011-07-01 2011-07-01 false On-board diagnostic test report. 85... Tests § 85.2223 On-board diagnostic test report. (a) Motorists whose vehicles fail the on-board diagnostic test described in § 85.2222 shall be provided with the on-board diagnostic test results, including...

[Occupational risk caused by ultrasound in medicine].

PubMed

Magnavita, N; Fileni, A

1994-01-01

Ultrasound (US) is extensively used in the medical field for its therapeutic and diagnostic applications. US units are commonly found in hospitals and clinics of all sizes, and a growing number of medical staff such as doctors and nurses are exposed to hand-transmitted ultrasound waves in their work-place. This review discusses the available information on the occupational risk of the operators using diagnostic and therapeutic ultrasound devices. The new occupational groups of medical workers who use ultrasound (diagnostic, surgical, sterilization, and physiotherapeutic) equipment are exposed to contact ultrasound waves. Contact ultrasound -- i.e., no airspace between the energy source and the biological tissue -- is much more hazardous than exposure to airborne ultrasound because air transmits less than one percent of this kind of energy. In spite of being a non-ionizing radiation with an excellent safety record, US is likely to induce some changes in the exposed organ. Recent Russian studies indicate that the hospital workers who have been long exposed to ultrasound at work may develop neurovascular dose-dependent disorders of the peripheral nervous system in the form of the angiodystonic syndrome of vegetative polyneuritis of the hands. In some Scandinavian studies, female physiotherapists (exposed to ultrasound and short waves) exhibit increased rate of spontaneous abortions and congenital malformations, but no definite conclusion can be drawn on the basis of these results alone. Trends in exposure for diagnostic ultrasound equipment over the last two decades show a continuous increase. While there is no reason for alarm, there is a growing need for avoiding unnecessary exposure to medical workers.

Imaging of rare appendicular non-acral soft-tissue chondromas in adults with histopathologic correlation.

PubMed

Nouh, Mohamed Ragab; Amr, Hanan Abd El-Aziz; Ali, Rola H

2018-06-01

Background Soft-tissue chondroma (STC) is a rare benign soft tissue tumor that arises primarily in acral extra-skeletal locations. Occasionally, STCs may arise in more proximal non-acral locations, accompanied by non-classic features that label them as indeterminate lesions and pose diagnostic challenge for both radiologists and pathologists alike. Purpose To explicate the potential of diagnostic imaging in the identification and characterization of appendicular non-acral STCs with emphasis on their morphologic magnetic resonance imaging (MRI) enhancement. Material and Methods Our clinical database records were searched for patients with histologically proven primary soft-tissue chondroid lesions over a five-year period. Two musculoskeletal (MSK) trained radiologists evaluated the imaging studies and an MSK pathologist revised the pathological findings. Results The study included six cases of appendicular non-acral STCs (mean age = 40.5 years). The mean size of the tumors was 5.6 cm, with four localized to the knee region, one in the thigh, and one in the sternoclavicular region. All cases showed high signal intensity matrix with low-signal intensity septa on T2-weighted MRI and post-contrast marginal/septal enhancement. The lesions were lobulated and lacked host tissue reaction except for one showing subjacent mild soft-tissue edema. Histologically, the cases lacked overt features of malignancy although one was originally misdiagnosed as chondrosarcoma. Conclusion Non-acral STCs are benign cartilaginous tumors that may pose a diagnostic challenge, both radiologically and pathologically. Collaborative imaging and pathologic workup is needed for better characterization of non-aggression of these lesions, and to avoid diagnostic pitfalls and unnecessary radical resections.

Diagnosing psychogenic nonepileptic seizures: Video-EEG monitoring, suggestive seizure induction and diagnostic certainty.

PubMed

Popkirov, Stoyan; Jungilligens, Johannes; Grönheit, Wenke; Wellmer, Jörg

2017-08-01

Psychogenic nonepileptic seizures (PNES) can remain undiagnosed for many years, leading to unnecessary medication and delayed treatment. A recent report by the International League Against Epilepsy Nonepileptic Seizures Task Force recommends a staged approach to the diagnosis of PNES (LaFrance, et al., 2013). We aimed to investigate its practical utility, and to apply the proposed classification to evaluate the role of long-term video-EEG monitoring (VEEG) and suggestive seizure induction (SSI) in PNES workup. Using electronic medical records, 122 inpatients (mean age 36.0±12.9years; 68% women) who received the diagnosis of PNES at our epilepsy center during a 4.3-year time period were included. There was an 82.8% agreement between diagnostic certainty documented at discharge and that assigned retroactively using the Task Force recommendations. In a minority of cases, having used the Task Force criteria could have encouraged the clinicians to give more certain diagnoses, exemplifying the Task Force report's utility. Both VEEG and SSI were effective at supporting high level diagnostic certainty. Interestingly, about one in four patients (26.2%) had a non-diagnostic ("negative") VEEG but a positive SSI. On average, this subgroup did not have significantly shorter mean VEEG recording times than VEEG-positive patients. However, VEEG-negative/SSI-positive patients had a significantly lower habitual seizure frequency than their counterparts. This finding emphasizes the utility of SSI in ascertaining the diagnosis of PNES in patients who do not have a spontaneous habitual event during VEEG due to, for example, low seizure frequency. Copyright © 2017 Elsevier Inc. All rights reserved.

43 CFR 3809.401 - Where do I file my plan of operations and what information must I include with it?

Code of Federal Regulations, 2011 CFR

2011-10-01

... would not result in unnecessary or undue degradation of public lands. (b) Your plan of operations must... BLM to determine that the plan of operations prevents unnecessary or undue degradation: (1) Operator... closure (including periods of seasonal closure) to prevent unnecessary or undue degradation. The interim...

National Aeronautics Research, Development, Test and Evaluation (RDT&E) Infrastructure Plan

DTIC Science & Technology

2011-01-01

addressed in the National Aeronautics R&D Plan, identi- fying unnecessary redundancy solely on the basis of infrastructure required to support H H13 ...near, mid, and far terms, and impact not only scramjet propulsion systems, but potential turbine-based combined cycle systems as well. Turbine Engine...Icing Test Facilities A greater understanding of the impact that icing conditions have on turbine engine opera- tions is needed to develop enhanced

42 CFR 415.180 - Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic...

Code of Federal Regulations, 2011 CFR

2011-10-01

... interpretation of diagnostic radiology and other diagnostic tests. 415.180 Section 415.180 Public Health CENTERS... for the interpretation of diagnostic radiology and other diagnostic tests. (a) General rule. Physician fee schedule payment is made for the interpretation of diagnostic radiology and other diagnostic tests...

42 CFR 415.180 - Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic...

Code of Federal Regulations, 2010 CFR

2010-10-01

... interpretation of diagnostic radiology and other diagnostic tests. 415.180 Section 415.180 Public Health CENTERS... for the interpretation of diagnostic radiology and other diagnostic tests. (a) General rule. Physician fee schedule payment is made for the interpretation of diagnostic radiology and other diagnostic tests...

Alternatives for jet engine control

NASA Technical Reports Server (NTRS)

Sain, M. K.

1983-01-01

The technical progress of researches on alternatives for jet engine control, is reported. The principal new activities involved the initial testing of an input design method for choosing the inputs to a non-linear system to aid the approximation of its tensor parameters, and the beginning of order reduction studies designed to remove unnecessary monomials from tensor models.

Optical Detection Of Cryogenic Leaks

NASA Technical Reports Server (NTRS)

Wyett, Lynn M.

1988-01-01

Conceptual system identifies leakage without requiring shutdown for testing. Proposed device detects and indicates leaks of cryogenic liquids automatically. Detector makes it unnecessary to shut equipment down so it can be checked for leakage by soap-bubble or helium-detection methods. Not necessary to mix special gases or other materials with cryogenic liquid flowing through equipment.

Lympho-glandular toxoplasmosis. A diagnosis often missed.

PubMed

Lake, K B; Van Dyke, J J; Abts, R M; Moyes, D R

1979-01-01

Lymphoglandular toxoplasmosis has a reputation for mimicking several other diseases, especially infectious mononucleosis. Thus, the correct diagnosis often is not discovered until common conditions have been ruled out and the patient has been subjected to excisional lymph node biopsy. The physician who considers toxoplasmosis early and orders appropriate serologic tests can spare the patient unnecessary surgery.

Impact of Knowledge Resources Linked to an Electronic Health Record on Frequency of Unnecessary Tests and Treatments

ERIC Educational Resources Information Center

Goodman, Kenneth; Grad, Roland; Pluye, Pierre; Nowacki, Amy; Hickner, John

2012-01-01

Introduction: Electronic knowledge resources have the potential to rapidly provide answers to clinicians' questions. We sought to determine clinicians' reasons for searching these resources, the rate of finding relevant information, and the perceived clinical impact of the information they retrieved. Methods: We asked general internists, family…

Proceedings of the Fourth Annual Workshop on the Use of Digital Computers in Process Control.

ERIC Educational Resources Information Center

Smith, Cecil L., Ed.

Contents: Computer hardware testing (results of vendor-user interaction); CODIL (a new language for process control programing); the design and implementation of control systems utilizing CRT display consoles; the systems contractor - valuable professional or unnecessary middle man; power station digital computer applications; from inspiration to…

Unnecessary roughness? Testing the hypothesis that predators destined for molecular gut-content analysis must be hand-collected to avoid cross-contamination

USDA-ARS?s Scientific Manuscript database

Molecular gut-content analysis enables direct detection of arthropod predation with minimal disruption of on-going ecosystem processes. Mass-collection methods, such as sweep-netting, vacuum sampling, and foliage beating, could lead to regurgitation or even rupturing of predators along with uneaten ...

Unnecessary Roughness? School Sports, Peer Networks, and Male Adolescent Violence

ERIC Educational Resources Information Center

Kreager, Derek A.

2007-01-01

This article examines the extent to which participation in high school interscholastic sports contributes to male violence. Deriving competing hypotheses from social control, social learning, and masculinity theories, I use data from the National Longitudinal Study of Adolescent Health to test if (1) type of sport and (2) peer athletic…

The impact of the "business" of pain medicine on patient care.

PubMed

Taylor, Mary Lou

2011-05-01

The objective of this article was to examine the impact on patient care of the growing economic forces in pain medicine. Chronic pain is a growing problem in the United States, as more people seek treatment than ever before. The practice of pain medicine is influenced by many market forces, including industry relationships with pain providers, lawmakers and insurance companies, direct-to-consumer advertising, insurance reimbursement patterns, and competition among health care systems and pain management providers. These economic factors can encourage innovation and efficiency and may increase access to pain treatment. However, they have also resulted in unrealistic expectations for pain relief, increased reliance on medications, widespread use of inadequately tested or unnecessary pain management diagnostic and treatment techniques, decreased use of some effective treatments, and lack of adequate pain education. Patients are undergoing more treatments, but there is little evidence of overall improved function. Following guidelines set out by the industry and pain medicine organizations, safeguarding against false or incomplete advertising, establishing easier methods for questioning advertising content, increasing the practice of evidence-based medicine, increasing government-sponsored research of definitive studies, and improving communication of efficacious treatment will facilitate the practice of ethical pain medicine and improve patient care. Wiley Periodicals, Inc.

Is it necessary to perform prophylactic cholecystectomy for all symptomatic gallbladder polyps diagnosed with ultrasound?

PubMed

Velidedeoğlu, Mehmet; Çitgez, Bülent; Arıkan, Akif Enes; Ayan, Fadıl

2017-01-01

The main aim of this study is to determine the necessity of cholecystectomy in patients with ultrasound diagnosed symptomatic polypoid lesions of the gallbladder. The data of 82 patients with polypoid lesions of the gallbladder who had cholecystectomy between 2000 and 2012 were analyzed retrospectively with preoperative ultrasound and histopathology results. The mean age was 48.05±11.18 years (range 25-74 years). All patients underwent preoperative ultrasound examination. Eighteen (22%) of the 82 patients were asymptomatic; their polypoid lesions of the gallbladder were detected with ultrasound during a check-up or other reasons. In 45 (55%) of cases pathology reported no polypoid lesions of the gallbladder. Right upper quadrant or epigastric pain was the most common symptom (41.46%) that led to hepatobiliary ultrasound, the other symptom was dyspepsia (36.59%). On preoperative ultrasound evaluation, 22 patients had multiple polyps, and 9 of these 22 patients had at least 3 polyps. There is an inaccuracy of ultrasound to detect polypoid lesions of the gallbladder. After diagnosing polypoid lesions of the gallbladder by using standard ultrasound, further pre-operative diagnostic tests are needed to help discriminating benign lesions from malignant ones, which may prevent unnecessary surgery regardless of symptoms.

Reduction of adult fingers visualized on pediatric intensive care unit (PICU) chest radiographs after radiation technologist and PICU staff radiation safety education.

PubMed

Tynan, Jennifer R; Duncan, Meghan D; Burbridge, Brent E

2009-10-01

A recent publication from our centre revealed a disturbing finding of a significant incidence of adult fingers seen on the pediatric intensive care unit (PICU) chest radiographs. This is inappropriate occupational exposure to diagnostic radiation. We hypothesized that the incidence of adult fingers on PICU chest radiographs would decline after radiation safety educational seminars were given to the medical radiation technologists and PICU staff. The present study's objectives were addressed by using a pretest-posttest design. Two cross-sectional PICU chest radiograph samples, taken before and after the administration of radiation safety education for our medical radiation technologists and PICU staff, were compared by using a chi2 test. There was a 61.2% and 76.9% reduction in extraneous adult fingers, directly exposed to the x-ray beam and those seen in the coned regions of the film, respectively, on PICU chest radiographs (66.7% reduction overall). This reduction was statistically significant (chi2 = 20.613, P < .001). Limiting unnecessary occupational radiation exposure is a critical issue in radiology. There was a statistically and clinically significant association between radiation safety education and the decreased number of adult fingers seen on PICU chest radiographs. This study provides preliminary evidence in favour of the benefit of radiation safety seminars.

Occult cancer detection in patients with hemostatic disorder and venous thromboembolism.

PubMed

Husseinzadeh, Holleh; Carrier, Marc

2018-03-01

There are physiologic ties between Von Willebrand Factor (VWF) and circulating tumor cells. VWF appears to play a role in tumor biology, but it is unclear whether cancer behavior differs in Von Willebrand Disease. In patients presenting with venous thromboembolism (VTE), occult cancer is frequently considered as an underlying cause. The prevalence of occult cancer after provoked VTE is low (3%); therefore, cancer screening in these patients is not routinely recommended. In those with unprovoked VTE, occult cancer is more prevalent, estimated between 4 and 10%. Due to this elevated risk, occult cancer screening is recommended in this population. Multiple studies have investigated whether a "limited" approach (including history and physical exam, basic labs, and chest X-ray) versus "extensive" approach (addition of advanced imaging, such as computer tomography) is more effective. Current data fails to demonstrate extensive screening strategies diagnose more occult cancer, miss fewer cancers during follow up, or improve cancer-related mortality. Furthermore, many patients may be needlessly exposed to unnecessary diagnostic procedures with their associated complications and costs, as well as significant anxiety. Therefore, the decision to perform additional testing should be made on a case-by-case basis. Additional studies are needed to identify subgroups of patients with unprovoked VTE at highest risk for occult cancer. Copyright © 2017 Elsevier Ltd. All rights reserved.

Combined fluorescence-Raman spectroscopy measurements with an optical fiber probe for the diagnosis of melanocytic lesions

NASA Astrophysics Data System (ADS)

Cosci, Alessandro; Cicchi, Riccardo; Rossari, Susanna; De Giorgi, Vincenzo; Massi, Daniela; Pavone, Francesco S.

2012-02-01

We have designed and developed an optical fiber-probe for spectroscopic measurements on human tissues. The experimental setup combines fluorescence spectroscopy and Raman spectroscopy in a multidimensional approach. Concerning fluorescence spectroscopy, the excitation is provided by two laser diodes, one emitting in the UV (378 nm) and the other emitting in the visible (445 nm). These two lasers are used to selectively excite fluorescence from NADH and FAD, which are among the brightest endogenous fluorophores in human tissues. For Raman and NIR spectroscopy, the excitation is provided by a third laser diode with 785 nm excitation wavelength. Laser light is delivered to the tissue through the central optical fiber of a fiber bundle. The surrounding 48 fibers of the bundle are used for collecting fluorescence and Raman and for delivering light to the spectrograph. Fluorescence and Raman spectra are acquired on a cooled CCD camera. The instrument has been tested on fresh human skin biopsies clinically diagnosed as malignant melanoma, melanocytic nevus, or healthy skin, finding an optimal correlation with the subsequent histological exam. In some cases our examination was not in agreement with the clinical observation, but it was with the histological exam, demonstrating that the system can potentially contribute to improve clinical diagnostic capabilities and hence reduce the number of unnecessary biopsies.

Double optical fibre-probe device for the diagnosis of melanocytic lesions

NASA Astrophysics Data System (ADS)

Cicchi, Riccardo; Cosci, Alessandro; Rossari, Susanna; De Giorgi, Vincenzo; Kapsokalyvas, Dimitrios; Massi, Daniela; Pavone, Francesco S.

2012-06-01

We have designed and developed an optical fiber-probe for spectroscopic measurements on human tissues. The experimental setup combines fluorescence spectroscopy and Raman spectroscopy in a multidimensional approach. Concerning fluorescence spectroscopy, the excitation is provided by two laser diodes, one emitting in the UV (378 nm) and the other emitting in the visible (445 nm). These two lasers are used to selectively excite fluorescence from NADH and FAD, which are among the brightest endogenous fluorophores in human tissues. For Raman and NIR spectroscopy, the excitation is provided by a third laser diode with 785 nm excitation wavelength. Laser light is delivered to the tissue through the central optical fiber of a fiber bundle. The surrounding 48 fibers of the bundle are used for collecting fluorescence and Raman and for delivering light to the spectrograph. Fluorescence and Raman spectra are acquired on a cooled CCD camera. The instrument has been tested on fresh human skin biopsies clinically diagnosed as malignant melanoma, melanocytic nevus, or healthy skin, finding an optimal correlation with the subsequent histological exam. In some cases our examination was not in agreement with the clinical observation, but it was with the histological exam, demonstrating that the system can potentially contribute to improve clinical diagnostic capabilities and hence reduce the number of unnecessary biopsies.

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema

PubMed Central

Suárez, Pedro Rodríguez; Gilart, Jorge Freixinet; Pérez, José María Hernández; Serhal, Mohamed Hussein; Artalejo, Antonio López

2012-01-01

Summary Background We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). Material/Methods From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ 2 and Fisher exact test. Results The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. Conclusions The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit. PMID:22739734

Retrospective Comparison of Cardiac Testing and Results on Inpatients with Low Pretest Probability Compared with Moderate/High Pretest Probability for Coronary Artery Disease.

PubMed

Lear, Aaron; Huber, Merritt; Canada, Amy; Robertson, Jessica; Bosman, Evan; Zyzanski, Stephen

2018-01-01

To determine whether admission, and provocative stress testing of patients who have ruled out for acute coronary syndrome put patients with low-risk category for coronary artery disease (CAD) at risk for false-positive provocative stress testing and unnecessary coronary angiogram/imaging. A retrospective chart review was performed on patients between 30 and 70 years old, with no pre-existing diagnosis of CAD, admitted to observation or inpatient status chest pain or related complaints. Included patients were categorized based on Duke Clinical Score for pretest probability for CAD into either low-risk group, or moderate/high-risk group. The inpatient course was compared including whether provocative stress testing was performed; results of stress testing; whether patients underwent further coronary imaging; and what the results of the further imaging showed. 543 patients were eligible: 305 low pretest probability, and 238 moderate/high pretest probability. No difference was found in rate of stress testing relative risk (RR) = 1.01 (95% CI, 0.852 to 1.192; P = 0); rate of positive or equivocal stress tests between the 2 groups: RR = 0.653 (95% CI, 0.415 to 1.028; P = .07,). Low-pretest-probability patients had a lower likelihood of positive coronary imaging after stress test, RR = 0.061 (95% CI, 0.004 to 0.957; P = .001). Follow-up provocative testing of all patients admitted/observed after emergency department presentation with chest pain is unlikely to find CAD in patients with low pretest probability. Testing all low-probability patients puts them at increased risk for unnecessary invasive confirmatory testing. Further prospective testing is needed to confirm these retrospective results. © Copyright 2018 by the American Board of Family Medicine.

Exposure to ionizing radiation during pregnancy: Perception of teratogenic risk and outcome

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bentur, Y.; Horlatsch, N.; Koren, G.

We quantified the perception of teratogenic risk in women attending the Motherisk program for counseling about diagnostic radiation in pregnancy (n = 50) and compared it with a control group of women exposed to nonteratogenic drugs and chemicals (n = 48). Before receiving known information about the specific exposure, women exposed to radiation assigned themselves a significantly higher teratogenic risk compared with the control group (25.5 +/- 4.3% versus 15.7 +/- 3.0% for major malformations, P less than 0.01). The post-consultation perception of teratogenic risk did not differ between the two groups. Special consideration and attention should be given whenmore » counseling pregnant women exposed to low-dose ionizing radiation, as their misperception of teratogenic risk may lead them to unnecessary termination of their pregnancy.« less

Lateralized hyperkinetic motor behavior.

PubMed

Krishnaiah, Balaji; Acharya, Jayant; Ahmed, Aiesha

2018-01-01

Seizures are followed by a post-ictal period, which is characterized by usual slowing of brain activity. This case report describes a 68-year old woman who presented with right-sided rhythmic, non-voluntary, semi-purposeful motor behavior that started 2 days after an episode of generalized seizure. Her initial electroencephalogram (EEG) showed beta activity with no evidence of epileptiform discharges. Computed tomography scan showed hypodensity in the left parieto-occipital region. Magnetic resonance imaging (MRI) showed restricted diffusion/fluid-attenuated inversion recovery hyperintensities in the left precentral and post-central gyrus. Unilateral compulsive motor behavior during the post-ictal state should be considered, and not confused with partial status epilepticus to avoid unnecessary treatment. Abnormal magnetic resonance imaging (MRI) findings, which are reversible, can help with the diagnostic and therapeutic approach.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-06-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-01-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Endoscopic Ultrasound Elastography: Current Clinical Use in Pancreas.

PubMed

Mondal, Utpal; Henkes, Nichole; Patel, Sandeep; Rosenkranz, Laura

2016-08-01

Elastography is a newer technique for the assessment of tissue elasticity using ultrasound. Cancerous tissue is known to be stiffer (hence, less elastic) than corresponding healthy tissue, and as a result, could be identified in an elasticity-based imaging. Ultrasound elastography has been used in the breast, thyroid, and cervix to differentiate malignant from benign neoplasms and to guide or avoid unnecessary biopsies. In the liver, elastography has enabled a noninvasive and reliable estimate of fibrosis. Endoscopic ultrasound has become a robust diagnostic and therapeutic tool for the management of pancreatic diseases. The addition of elastography to endoscopic ultrasound enabled further characterization of pancreas lesions, and several European and Asian studies have reported encouraging results. The current clinical role of endoscopic ultrasound elastography in the management of pancreas disorders and related literature are reviewed.

Acute colonic pseudoobstruction in a child with sickle cell disease treated with neostigmine.

PubMed

Khosla, Arjun; Ponsky, Todd A

2008-12-01

Sickle cell disease is a disorder that produces significant morbidity and mortality. Vaso-occlusive pain crises are the most common presenting symptom associated with sickle cell patients. A rare, yet important to recognize, complication of sickle cell disease is acute colonic pseudoobstruction, also known as Ogilvie's syndrome. These patients may present with symptoms that are difficult to distinguish from other etiologies of abdominal pain, but a thorough diagnostic workup can provide important clues. Furthermore, there is no agreement on optimal treatment of pseudoobstruction. We report the first pediatric case of acute pseudoobstruction secondary to sickle cell disease that was treated successfully with neostigmine. Early recognition of this phenomenon is important as it alters patient management, can be treated medically, and may avoid unnecessary surgical intervention.

Pediatric Somatic Symptom Disorders.

PubMed

Malas, Nasuh; Ortiz-Aguayo, Roberto; Giles, Lisa; Ibeziako, Patricia

2017-02-01

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

Extremely large breast abscess in a breastfeeding mother.

PubMed

Martic, Krešimir; Vasilj, Oliver

2012-11-01

Puerperal mastitis often occurs in younger primiparous women. Most cases occur between 3 and 8 weeks postpartum. If mastitis results in the formation of a breast abscess, surgical drainage or needle aspiration is most commonly performed. We report a case of an extremely large breast abscess in a primiparous 20-year-old woman, which presented 6 weeks postpartum. Surgical incision and evacuation of 2 liters of exudate were performed, and intravenous antibiotics therapy was administered. On the sixth day after incision, we secondarily closed the wound. Examination after 3 months showed symmetrical breasts with a small scar in the incision area of the right breast. A high degree of suspicion and adequate diagnostic procedures are essential to avoid delay in the treatment of mastitis and breast abscess and thereby prevent unnecessary surgical treatment.

Successful Treatment of Abdominal Cutaneous Entrapment Syndrome Using Ultrasound Guided Injection

PubMed Central

Hong, Myong Joo; Seo, Dong Hyuk

2013-01-01

There are various origins for chronic abdominal pain. About 10-30% of patients with chronic abdominal pain have abdominal wall pain. Unfortunately, abdominal wall pain is not thought to be the first origin of chronic abdominal pain; therefore, patients usually undergo extensive examinations, including diagnostic laparoscopic surgery. Entrapment of abdominal cutaneous nerves at the muscular foramen of the rectus abdominis is a rare cause of abdominal wall pain. If abdominal wall pain is considered in earlier stage of chronic abdominal pain, unnecessary invasive procedures are not required and patients will reach symptom free condition as soon as the diagnosis is made. Here, we report a case of successful treatment of a patient with abdominal cutaneous nerve entrapment syndrome by ultrasound guided injection therapy. PMID:23862004

[Autochthonous acute viral and bacterial infections of the central nervous system (meningitis and encephalitis)].

PubMed

Pérez-Ruiz, Mercedes; Vicente, Diego; Navarro-Marí, José María

2008-07-01

Rapid diagnosis of acute viral and bacterial infections of the central nervous system (meningitis and encephalitis) is highly important for the clinical management of the patient and helps to establish early therapy that may solve life-threatening situations, to avoid unnecessary empirical treatments, to reduce hospital stay, and to facilitate appropriate interventions in the context of public health. Molecular techniques, especially real-time polymerase chain reaction, have become the fastest and most sensitive diagnostic procedures for autochthonous viral meningitis and encephalitis, and their role is becoming increasingly important for the diagnosis and control of most frequent acute bacterial meningitides. Automatic and closed systems may encourage the widespread and systematic use of molecular techniques for the diagnosis of these neurological syndromes in most laboratories.

[Quo vadis pathologia? An elderly clinicians meditations about autopsies].

PubMed

Iványi, J

1998-02-08

Relying on his own experience and the relevant literature of the past 15 years, the author analyzes the causes of the decrease in the number of autopsies. He disagrees with those who, referring to the application of state-of-the art examination methods, dismiss "the ultimate audit" as unnecessary and only suggest selection. Careful autopsies can still be rendered an authentic and reliable picture of treatment of the deceased on the one hand, and provide information about diagnostic difficulties as well as the possible mistakes and errors on the other. This is especially true of the elderly deceased usually with multimorbidity. As well as several aspects of the cooperation between the pathologist and the clinician there is the didactic importance of autopsies that should also be emphasized.

High-Value, Cost-Conscious Care: Iterative Systems-Based Interventions to Reduce Unnecessary Laboratory Testing.

PubMed

Sadowski, Brett W; Lane, Alison B; Wood, Shannon M; Robinson, Sara L; Kim, Chin Hee

2017-09-01

Inappropriate testing contributes to soaring healthcare costs within the United States, and teaching hospitals are vulnerable to providing care largely for academic development. Via its "Choosing Wisely" campaign, the American Board of Internal Medicine recommends avoiding repetitive testing for stable inpatients. We designed systems-based interventions to reduce laboratory orders for patients admitted to the wards at an academic facility. We identified the computer-based order entry system as an appropriate target for sustainable intervention. The admission order set had allowed multiple routine tests to be ordered repetitively each day. Our iterative study included interventions on the automated order set and cost displays at order entry. The primary outcome was number of routine tests controlled for inpatient days compared with the preceding year. Secondary outcomes included cost savings, delays in care, and adverse events. Data were collected over a 2-month period following interventions in sequential years and compared with the year prior. The first intervention led to 0.97 fewer laboratory tests per inpatient day (19.4%). The second intervention led to sustained reduction, although by less of a margin than order set modifications alone (15.3%). When extrapolating the results utilizing fees from the Centers for Medicare and Medicaid Services, there was a cost savings of $290,000 over 2 years. Qualitative survey data did not suggest an increase in care delays or near-miss events. This series of interventions targeting unnecessary testing demonstrated a sustained reduction in the number of routine tests ordered, without adverse effects on clinical care. Published by Elsevier Inc.

Estimated effect of an integrated approach to suspected deep venous thrombosis using limited-compression ultrasound.

PubMed

Poley, Rachel A; Newbigging, Joseph L; Sivilotti, Marco L A

2014-09-01

Deep vein thrombosis (DVT) is both common and serious, yet the desire to never miss the diagnosis, coupled with the low specificity of D-dimer testing, results in high imaging rates, return visits, and empirical anticoagulation. The objective of this study was to evaluate a new approach incorporating bedside limited-compression ultrasound (LC US) by emergency physicians (EPs) into the workup strategy for DVT. This was a cross-sectional observational study of emergency department (ED) patients with suspected DVT. Patients on anticoagulants; those with chronic DVT, leg cast, or amputation; or when the results of comprehensive imaging were already known were excluded. All patients were treated in the usual fashion based on the protocol in use at the center, including comprehensive imaging based on the modified Wells score and serum D-dimer testing. Seventeen physicians were trained and performed LC US in all subjects. The authors identified a priori an alternate workup strategy in which DVT would be ruled out in "DVT unlikely" (Wells score < 2) patients if the LC US was negative and in "DVT likely" (Wells score ≥ 2) patients if both the LC US and the D-dimer were negative. The criterion standard was based on comprehensive imaging interpreted by radiologists blinded to LC US findings and by structured medical record review at 6 months in patients without comprehensive imaging. A total of 227 patients were enrolled (47% DVT likely), of whom 24 had DVT. The LC US was positive in 27 cases (21 actually DVT positive), indeterminate in 28 (one DVT positive), and negative in 172 (two DVT positive). Of 130 patients deemed DVT negative by the new strategy, one had confirmed DVT (miss rate = 0.8%; 95% confidence interval [CI] = 0.1% to 4.0%), but this patient had been misclassified by the treating physician as low risk by Wells criteria. The stand-alone sensitivity and specificity of LC US were 91% (95% CI = 70% to 98%) and 97% (95% CI = 92% to 99%), respectively. Incorporating LC US into the diagnostic approach would have reduced the rate of comprehensive imaging from 70% to 43%, D-dimer testing from 100% to 33%, and the mean time to diagnostic certainty by 5.0 hours and avoided 24 (11%) return visits for imaging and 10 (4.4%) cases of unnecessary anticoagulation. In 19% of cases, the treating and scanning physician disagreed whether the patient was DVT likely or DVT unlikely based on Wells score (κ = 0.62; 95% CI = 0.48 to 0.77). Limited-compression US holds promise as one component of the diagnostic approach to DVT, but should not be used as a stand-alone test due to imperfect sensitivity. Tradeoffs in diagnostic efficiency for the sake of perfect sensitivity remain a difficult issue collectively in emergency medicine (EM), but need to be scrutinized carefully in light of the costs of overinvestigation, delays in diagnosis, and risks of empirical anticoagulation. © 2014 by the Society for Academic Emergency Medicine.

Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines.

PubMed

James, C D; Hanson, K; Solon, O; Whitty, C J M; Peabody, J

2011-08-01

To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care. Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed. Philippines. One hundred and forty-three public and private physicians in the Philippines, collected in November 2003-December 2004 and September 2006-June 2007. CPVs administered to physicians. Process quality measures (accounting for the possibility of both over-treatment and under-treatment). Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%). Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.

The Cellient automated cell block system is useful in the differential diagnosis of atypical glandular cells in Papanicolaou tests.

PubMed

Xing, Wei; Hou, April Y; Fischer, Andrew; Owens, Christopher L; Jiang, Zhong

2014-01-01

Atypical glandular cells (AGC) is a very important diagnosis in gynecological cytology. In the current study, the authors investigated the usefulness of Cellient cell blocks (CB) for characterizing AGC on Papanicolaou (Pap) tests. A total of 148 patients with an AGC diagnosis based on Pap tests by cytotechnologists and referred to cytopathologists were studied. Among these patients, there were 68 patients with CB preparations and 80 patients with Pap tests only (TP-AGC group). Follow-up results by Pap tests or biopsies were obtained in 117 of 148 patients. The median follow-up was 13 months (range, 1 month-36 months). Of the 68 patients with CBs, 31 (46%) were reclassified as negative for dysplasia or low-grade intraepithelial lesion; 30 patients (44%) retained a diagnosis of AGC (CB-AGC group); and 7 patients (10%) were given specific diagnoses of high-grade intraepithelial lesion (3 patients), endocervical adenocarcinoma in situ (1 patient), and invasive adenocarcinoma (3 patients). On follow-up, the CB-AGC group was found to have a significantly lower rate of negative/low-grade squamous intraepithelial lesion diagnoses compared with the TP-AGC group (55% vs 85%; P= .006). The CB-AGC group had a significantly higher rate of endocervical or endometrial adenocarcinoma compared with the TP-AGC group (36% vs 8%; P= .003) at the time of follow-up. The rates of high-grade squamous intraepithelial lesion were not found to be statistically different between these 2 groups (9% vs 7%; P= .66). The Cellient CB is a useful technique to further categorize a diagnosis of AGC on Pap tests. Using the Cellient CB system, the pathologist has the ability to improve the diagnostic accuracy of AGC so that unnecessary colposcopic evaluation or biopsies can be avoided. © 2013 American Cancer Society.

Multicenter, randomized trial of quantitative pretest probability to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.

PubMed

Kline, Jeffrey A; Jones, Alan E; Shapiro, Nathan I; Hernandez, Jackeline; Hogg, Melanie M; Troyer, Jennifer; Nelson, R Darrel

2014-01-01

Use of pretest probability can reduce unnecessary testing. We hypothesize that quantitative pretest probability, linked to evidence-based management strategies, can reduce unnecessary radiation exposure and cost in low-risk patients with symptoms suggestive of acute coronary syndrome and pulmonary embolism. This was a prospective, 4-center, randomized controlled trial of decision support effectiveness. Subjects were adults with chest pain and dyspnea, nondiagnostic ECGs, and no obvious diagnosis. The clinician provided data needed to compute pretest probabilities from a Web-based system. Clinicians randomized to the intervention group received the pretest probability estimates for both acute coronary syndrome and pulmonary embolism and suggested clinical actions designed to lower radiation exposure and cost. The control group received nothing. Patients were followed for 90 days. The primary outcome and sample size of 550 was predicated on a significant reduction in the proportion of healthy patients exposed to >5 mSv chest radiation. A total of 550 patients were randomized, and 541 had complete data. The proportion with >5 mSv to the chest and no significant cardiopulmonary diagnosis within 90 days was reduced from 33% to 25% (P=0.038). The intervention group had significantly lower median chest radiation exposure (0.06 versus 0.34 mSv; P=0.037, Mann-Whitney U test) and lower median costs ($934 versus $1275; P=0.018) for medical care. Adverse events occurred in 16% of controls and 11% in the intervention group (P=0.06). Provision of pretest probability and prescriptive advice reduced radiation exposure and cost of care in low-risk ambulatory patients with symptoms of acute coronary syndrome and pulmonary embolism. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01059500.

Impact of smartphone digital photography, email, and media communication on emergency room visits post-hypospadias repair.

PubMed

Chua, Michael E; Saunders, Megan A; Bowlin, Paul R; Ming, Jessica M; Lopes, Roberto Iglesias; Farhat, Walid A; Dos Santos, Joana

2017-01-01

Advances in communication technology are shaping our medical practice. To date, there is no clear evidence that this mode of communication will have any effect on unnecessary postoperative emergency room (ER) visits. We aim to evaluate the effect of email and media communication with application of smartphone digital photography on post-hypospadias repair ER visit rates. This prospective cohort study included all patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented for smartphone photography and email communication and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician, who was blinded of patient group assignment. The reasons were categorized as: unnecessary ER visit, indicated ER visit, or visit unrelated to hypospadias surgery. Chi-square test and T-test were used for statistical analysis. Relative risk (RR) and corresponding 95% confidence interval (CI) were also calculated. Statistical significance was set at p<0.05. Over a 14-month period, 96 patients underwent hypospadias repair (81 in Group A, 15 in Group B 5). No significant difference was noted between groups for overall ER return rate (RR 0.46, 95% CI 0.21, 1.0). However, the number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (RR 0.14, 95% CI 0.035, 0.56); likewise, a higher number of ER visits requiring intervention was noted in Group A compared with Group B, although statistically this was not significant (RR 1.67, 95% CI 0.23, 12.21). Email communication with the use of smartphone digital photography significantly reduced the number of unnecessary ER visits for post-hypospadias wound checks.

High Velocity Firings of Slug Projectiles in a Double-Travel 120-MM Gun System

DTIC Science & Technology

1991-04-01

constraints presented by TBD. This charge configuration was then tested using aluminium slug projectiles to avoid the unnecessary expenditure of APFSDS...test projectile was a depleted uranium alloy (U-.75Ti) rod with a standard, four piece, aluminum sabot assembly. The launch package had a nominal...the rod is shown in Figure 2. Figure 2. Scaled, Long Rod Penetrator. Figure 3. Aluminium Slug Projectile. The aluminium slug rounds, fired at Range 18

42 CFR 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... in the 80000 series of the Current Procedural Terminology published by the American Medical... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Medical and Other Health Services § 410.32 Diagnostic x-ray tests, diagnostic laboratory...

42 CFR 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Procedural Terminology published by the American Medical Association. (3) Levels of supervision. Except where... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Medical and Other Health Services § 410.32 Diagnostic x-ray tests, diagnostic laboratory...

[The unnecessary application of central venous catheterization in surgical patients].

PubMed

Uemura, Keiko; Inoue, Satoki; Kawaguchi, Masahiko

2018-04-06

Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement. Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement. In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR=1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR=0.961/10min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR=2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p=0.032, OR=2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p=0.0536, OR=2.115, 95% CI 0.988-4.526). More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on holidays, during low risk surgery, with a short duration of anesthesia, or in cases that do not require postoperative intensive care. Copyright © 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Safe and sustainable increases in day case emergency surgery.

PubMed

Hotchen, Andrew J; Coleman, Grant; O'Callaghan, John M; McWhinnie, Doug

2016-03-01

Selected patients referred to emergency general surgery departments are suitable for day case emergency surgery with no overnight hospital stay. There are no well-described sustainable pathways for these expedited operations and in many hospitals patients undergo unnecessary admissions and experience long waiting times. The authors proposed a new, sustainable, day case emergency surgery pathway which was implemented to streamline the assessment, treatment and discharge of acute surgical referrals. It requires rapid assessment of the patient by a senior clinician, and ready availability of diagnostic services and operating facilities. To assess this pathway, the authors conducted a prospective audit of general surgical referrals to a district general hospital in the UK. During the inclusion period 746 emergency referrals were assessed, 281 (37%) of these underwent an operation. Over a 5-month investigation period, the audit found that approximately 27% of all emergency general surgery patients requiring an operation could be managed with day case emergency surgery. This figure was maintained throughout the duration of the study. Operations included incision and drainage of abscesses, incarcerated hernia repairs and appendicectomies. The average length of stay of all surgical admissions decreased from 5 days to less than 3 days and the median time to senior review was 30 minutes. The authors have developed a pathway involving permanent members of the surgical assessment team that is sustainable over a 5-month period. The pathway has allowed rapid assessment of patients and reduced unnecessary inpatient stay in a sustainable and reproducible manner.

Concomitant occurrence of macroprolactin, exercise-induced amenorrhea, and a pituitary lesion: a diagnostic pitfall. Case report.

PubMed

Cattaneo, F A; Fahie-Wilson, M N

2001-08-01

The authors report the case of a 37-year-old woman who presented with amenorrhea and an increased level of serum prolactin. Magnetic resonance images of the pituitary revealed a lesion with characteristics consistent with those of a microadenoma. Transsphenoidal exploration was performed, but a prolactinoma was not found. After endocrinological review, the patient's hyperprolactinemia was found to be caused by the presence of macroprolactin and her amenorrhea was due to intense exercise and low body weight. Macroprolactin is an isoform of prolactin that is variably reactive in assays for prolactin, but displays minimum bioactivity in vivo. Patients with macroprolactin are mostly asymptomatic. This phenomenon may cause elevated prolactin values, which the authors view as apparent hyperprolactinemia. The presence of macroprolactin is an underrecognized problem, occurring in as many as 15 to 20% of patients with elevated prolactin values and often leading to unnecessary, expensive diagnostic procedures and inappropriate treatment. The presence of macroprolactin should always be suspected when the patient's clinical history or clinical or radiological data are incompatible with the prolactin value. Physicians dealing with diagnosis and treatment of hyperprolactinemia (general practitioners, gynecologists, neurosurgeons, endocrinologists, and biochemists) should be aware of the potentially misleading nature of macroprolactin.

[Optimal use of MRI mammography from the economic viewpoint].

PubMed

Oellinger, H; Blohmer, J U; Siewert, C; Hadijuana, J; Gutberlet, M; Ehrenstein, T; Lichtenegger, W; Felix, R

1998-01-01

With the introduction of the contrast agent gadolinum DTPA there were hopes that "MRM" would prove to be the investigatory technique that would largely solve the problems of breast diagnostics. However, after the early years of acceptance, the new method of investigation became a subject of controversy. Nonetheless, MRM today occupies a recognized place in diagnostics for certain indications. It is still true, however, that reliable use of this procedure requires a great deal of experience, since there is a relatively large area of overlap between benign and malignant tumors. Further, the costs are significantly higher than those for conventional methods of investigation. New studies that have been conducted at the Charité, Campus Virchow Medical Center in Berlin, suggest that, if one takes the relevant indications into account, MRM can be economic and contribute significantly to cost reduction. Application of a newly developed software package has shown that the good discrimination in a suspect area resulting from contrast agent enhancement makes possible a reliable differentiation between malignant and benign tissue changes. A further result was that, when certain boundary conditions are satisfied, a contrast agent bolus of 0.1 mmol/kg BW is sufficient, making a double dose (0.2 mmol/kg BW) unnecessary.

Epidemiology, Diagnosis, and Treatment of Scabies in a Dermatology Office.

PubMed

Anderson, Kathryn L; Strowd, Lindsay C

Scabies is a neglected skin disease, and little is known about current incidence and treatment patterns in the United States. The purpose of this study was to examine demographic data, treatment types, success of treatment, and misdiagnosis rate of scabies in an outpatient dermatology clinic. A retrospective chart review of patients diagnosed with scabies within the past 5 years was performed. A total of 459 charts were identified, with 428 meeting inclusion criteria. Demographic data, diagnostic method, treatment choice, misdiagnosis rate, treatment failure, and itching after scabies are also reported. Children were the largest age group diagnosed with scabies, at 38%. Males (54%) were diagnosed with scabies more than females. The majority of diagnoses were made by visualizing ova, feces, or mites on light microscopy (58%). At the time of diagnosis, 45% of patients had been misdiagnosed by another provider. Topical permethrin was the most common treatment used (69%), followed by a combination of topical permethrin and oral ivermectin (23%), oral ivermectin (7%), and other treatments (1%). Our findings suggest that more accurate and faster diagnostic methods are needed to limit unnecessary treatment and expedite appropriate therapy for scabies. © Copyright 2017 by the American Board of Family Medicine.

Clinical Tests Combined with Color Doppler Versus Color Doppler Alone in Identifying Incompetent Perforator Veins of the Lower Limb: A Prospective Analytical Study

PubMed Central

Vignesh, Narayan; Venkatachalam, J; Vijayakumar, Chellappa; Sudharsanan, Sundaramurthi

2018-01-01

Background The color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement. Objective To compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb. Methods This was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg’s test, multiple tourniquet tests and, the Fegan’s tests were performed and incompetent perforators were marked on a template as ‘C’ to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as ‘D’. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler ‘D’ marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as ‘D’ positive or ’C’ and ‘D’ positive and were recorded in the specified proforma. Results It was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients. Conclusion A combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients. PMID:29531879

Evaluating wood-based composites for incipient fungal decay with the immunodiagnostic wood decay test.

Treesearch

C.A. Clausen; L. Haughton; C. Murphy

2003-01-01

Early and accurate detection of the extent of fungal deterioration during forensic inspection of the building envelope would eliminate excessive or unnecessary replacement of wood-based building materials. Areas of water infiltration in wood-framed building envelopes in the Pacific Northwest were evaluated visually and sampled for moisture content. Wood samples were...

75 FR 38422 - Procedures for Transportation Workplace Drug and Alcohol Testing Programs

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-02

... minimizing the unnecessary waste of paper and expense that would have been caused by throwing away forms that... past the proposed mandatory use date of January 1, 2011. Two commenters asked for guidance on what would happen if an old ATF was used past the January 1, 2011 mandatory use date. The Department agrees...

42 CFR 414.508 - Payment for a new clinical diagnostic laboratory test.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Payment for a new clinical diagnostic laboratory... SERVICES Payment for New Clinical Diagnostic Laboratory Tests § 414.508 Payment for a new clinical diagnostic laboratory test. For a new clinical diagnostic laboratory test that is assigned a new or...

20 CFR 404.1519m - Diagnostic tests or procedures.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Diagnostic tests or procedures. 404.1519m... Report Content § 404.1519m Diagnostic tests or procedures. We will request the results of any diagnostic... will not order diagnostic tests or procedures that involve significant risk to you, such as myelograms...

42 CFR 414.508 - Payment for a new clinical diagnostic laboratory test.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Payment for a new clinical diagnostic laboratory... SERVICES Payment for New Clinical Diagnostic Laboratory Tests § 414.508 Payment for a new clinical diagnostic laboratory test. For a new clinical diagnostic laboratory test that is assigned a new or...

Poor performance of the rapid test for human brucellosis in health facilities in Kenya.

PubMed

de Glanville, William A; Conde-Álvarez, Raquel; Moriyón, Ignacio; Njeru, John; Díaz, Ramón; Cook, Elizabeth A J; Morin, Matilda; Bronsvoort, Barend M de C; Thomas, Lian F; Kariuki, Samuel; Fèvre, Eric M

2017-04-01

Human brucellosis is considered to be an important but typically under-diagnosed cause of febrile illness in many low and middle-income countries. In Kenya, and throughout East Africa, laboratory diagnosis for the disease is based primarily on the febrile antigen Brucella agglutination test (FBAT), yet few studies of the diagnostic accuracy of this test exist. Assessment of the performance of the FBAT is essential for its appropriate clinical use, as well as for evaluating surveillance data reported by public health systems. To assess FBAT performance, we collected sera from people with symptoms compatible with brucellosis attending two health facilities in Busia County, Kenya. Sera were tested using the FBAT and results compared with those from the Rose Bengal Test (RBT), an assay with well-known performance characteristics. Positives on either test were confirmed using the classical serum agglutination test (SAT)-Coombs test combination and a rapid IgM/IgG lateral flow immunochromatography assay (LFA). A questionnaire focussing on known risk factors for exposure to Brucella spp. was also conducted, and relationships with FBAT positivity examined using logistic regression. Out of 825 recruited individuals, 162 (19.6%) were classified as positive using the FBAT. In contrast, only eight (1.0%) were positive using the RBT. Of the 162 FBAT positives, one (0.62%) had an atypical agglutination in SAT and three (1.9%) showed low Coombs titres. Out of 148 FBAT positive individuals tested using the LFA, five (3.4%) were IgM positive and none were IgG positive. Poor or no correlation was observed between FBAT results and most established risk factors for Brucella infection. We observed substantial disagreement between the FBAT and a number of well-known serological tests, with the majority of reactive FBAT results appearing to be false positives. Poor FBAT specificity, combined with a lack of confirmatory testing, strongly suggests overdiagnosis of brucellosis is common in this low prevalence setting. This is expected to have important economic impacts on affected patients subjected to the long and likely unnecessary courses of multiple antibiotics required for treatment of the disease.

Poor performance of the rapid test for human brucellosis in health facilities in Kenya

PubMed Central

Conde-Álvarez, Raquel; Moriyón, Ignacio; Njeru, John; Díaz, Ramón; Cook, Elizabeth A. J.; Morin, Matilda; Bronsvoort, Barend M. de C.; Thomas, Lian F.; Kariuki, Samuel; Fèvre, Eric M.

2017-01-01

Human brucellosis is considered to be an important but typically under-diagnosed cause of febrile illness in many low and middle-income countries. In Kenya, and throughout East Africa, laboratory diagnosis for the disease is based primarily on the febrile antigen Brucella agglutination test (FBAT), yet few studies of the diagnostic accuracy of this test exist. Assessment of the performance of the FBAT is essential for its appropriate clinical use, as well as for evaluating surveillance data reported by public health systems. To assess FBAT performance, we collected sera from people with symptoms compatible with brucellosis attending two health facilities in Busia County, Kenya. Sera were tested using the FBAT and results compared with those from the Rose Bengal Test (RBT), an assay with well-known performance characteristics. Positives on either test were confirmed using the classical serum agglutination test (SAT)-Coombs test combination and a rapid IgM/IgG lateral flow immunochromatography assay (LFA). A questionnaire focussing on known risk factors for exposure to Brucella spp. was also conducted, and relationships with FBAT positivity examined using logistic regression. Out of 825 recruited individuals, 162 (19.6%) were classified as positive using the FBAT. In contrast, only eight (1.0%) were positive using the RBT. Of the 162 FBAT positives, one (0.62%) had an atypical agglutination in SAT and three (1.9%) showed low Coombs titres. Out of 148 FBAT positive individuals tested using the LFA, five (3.4%) were IgM positive and none were IgG positive. Poor or no correlation was observed between FBAT results and most established risk factors for Brucella infection. We observed substantial disagreement between the FBAT and a number of well-known serological tests, with the majority of reactive FBAT results appearing to be false positives. Poor FBAT specificity, combined with a lack of confirmatory testing, strongly suggests overdiagnosis of brucellosis is common in this low prevalence setting. This is expected to have important economic impacts on affected patients subjected to the long and likely unnecessary courses of multiple antibiotics required for treatment of the disease. PMID:28388625

Validation of a New Small-Volume Sodium Citrate Collection Tube for Coagulation Testing in Critically Ill Patients with Coagulopathy.

PubMed

Adam, Elisabeth H; Zacharowski, Kai; Hintereder, Gudrun; Raimann, Florian; Meybohm, Patrick

2018-06-01

Blood loss due to phlebotomy leads to hospital-acquired anemia and more frequent blood transfusions that may be associated with increased risk of morbidity and mortality in critically ill patients. Multiple blood conservation strategies have been proposed in the context of patient blood management to minimize blood loss. Here, we evaluated a new small-volume sodium citrate collection tube for coagulation testing in critically ill patients. In 46 critically adult ill patients admitted to an interdisciplinary intensive care unit, we prospectively compared small-volume (1.8 mL) sodium citrate tubes with the conventional (3 mL) sodium citrate tubes. The main inclusion criterium was a proven coagulopathy (Quick < 60% and/or aPTT > 40 second) due to anticoagulation therapy or perioperative coagulopathy. In total, 92 coagulation analyses were obtained. Linear correlation analysis detected a positive relationship for 7 coagulation parameters (Prothrombin Time, r = 0.987; INR, r = 0.985; activated Partial Thromboplastin Time, r = 0.967; Thrombin Clotting Time, r = 0.969; Fibrinogen, r = 0.986; Antithrombin, r = 0.988; DDimer, r = 0.969). Bland-Altman analyses revealed an absolute mean of differences of almost zero. Ninety-five percent of data were within two standard deviations of the mean difference suggesting interchangeability. As systematic deviations between measured parameters of the two tubes were very unlikely, test results of small-volume (1.8 mL) sodium citrate tubes were equal to conventional (3 mL) sodium citrate tubes and can be considered interchangeable. Small-volume sodium citrate tubes reduced unnecessary diagnostic-related blood loss by about 40% and, therefore, should be the new standard of care for routine coagulation analysis in critically ill patients.

A theory-based decision aid for patients with cancer: results of feasibility and acceptability testing of DecisionKEYS for cancer.

PubMed

Hollen, Patricia J; Gralla, Richard J; Jones, Randy A; Thomas, Christopher Y; Brenin, David R; Weiss, Geoffrey R; Schroen, Anneke T; Petroni, Gina R

2013-03-01

Appropriate utilization of treatment is a goal for all patients undergoing cancer treatment. Proper treatment maximizes benefit and limits exposure to unnecessary measures. This report describes findings of the feasibility and acceptability of implementing a short, clinic-based decision aid and presents an in-depth clinical profile of the participants. This descriptive study used a prospective, quantitative approach to obtain the feasibility and acceptability of a decision aid (DecisionKEYS for Balancing Choices) for use in clinical settings. It combined results of trials of patients with three different common malignancies. All groups used the same decision aid series. Participants included 80 patients with solid tumors (22 with newly diagnosed breast cancer, 19 with advanced prostate cancer, and 39 with advanced lung cancer) and their 80 supporters as well as their physicians and nurses, for a total of 160 participants and 10 health professionals. The decision aid was highly acceptable to patient and supporter participants in all diagnostic groups. It was feasible for use in clinic settings; the overall value was rated highly. Of six physicians, all found the interactive format with the help of the nurse as feasible and acceptable. Nurses also rated the decision aid favorably. This intervention provides the opportunity to enhance decision making about cancer treatment and warrants further study including larger and more diverse groups. Strengths of the study included a theoretical grounding, feasibility testing of a practical clinic-based intervention, and summative evaluation of acceptability of the intervention by patient and supporter pairs. Further research also is needed to test the effectiveness of the decision aid in diverse clinical settings and to determine if this intervention can decrease overall costs.

30 CFR 250.525 - What do I submit if my casing diagnostic test requires action?

Code of Federal Regulations, 2011 CFR

2011-07-01

... 30 Mineral Resources 2 2011-07-01 2011-07-01 false What do I submit if my casing diagnostic test... if my casing diagnostic test requires action? Within 14 days after you perform a casing diagnostic... Corrective Action Plan within 30 days of the diagnostic test. (b) a casing pressure request, Regional...

Triage of Women with Low-Grade Cervical Lesions - HPV mRNA Testing versus Repeat Cytology

PubMed Central

Sørbye, Sveinung Wergeland; Arbyn, Marc; Fismen, Silje; Gutteberg, Tore Jarl; Mortensen, Elin Synnøve

2011-01-01

Background In Norway, women with low-grade squamous intraepithelial lesions (LSIL) are followed up after six months in order to decide whether they should undergo further follow-up or be referred back to the screening interval of three years. A high specificity and positive predictive value (PPV) of the triage test is important to avoid unnecessary diagnostic and therapeutic procedures. Materials and Methods At the University Hospital of North Norway, repeat cytology and the HPV mRNA test PreTect HPV-Proofer, detecting E6/E7 mRNA from HPV types 16, 18, 31, 33 and 45, are used in triage of women with ASC-US and LSIL. In this study, women with LSIL cytology in the period 2005–2008 were included (n = 522). Two triage methods were evaluated in two separate groups: repeat cytology only (n = 225) and HPV mRNA testing in addition to repeat cytology (n = 297). Histologically confirmed cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) was used as the study endpoint. Results Of 522 women with LSIL, 207 had biopsies and 125 of them had CIN2+. The sensitivity and specificity of repeat cytology (ASC-US or worse) were 85.7% (95% confidence interval (CI): 72.1, 92.2) and 54.4 % (95% CI: 46.9, 61.9), respectively. The sensitivity and specificity of the HPV mRNA test were 94.2% (95% CI: 88.7, 99.7) and 86.0% (95% CI: 81.5, 90.5), respectively. The PPV of repeat cytology was 38.4% (95% CI: 29.9, 46.9) compared to 67.0% (95% CI: 57.7, 76.4) of the HPV mRNA test. Conclusion HPV mRNA testing was more sensitive and specific than repeat cytology in triage of women with LSIL cytology. In addition, the HPV mRNA test showed higher PPV. These data indicate that the HPV mRNA test is a better triage test for women with LSIL than repeat cytology. PMID:21918682

Bacterial Contamination During Diagnostic and Interventional Neuroangiography is a Frequent Finding: But Does It Matter? An Observational Study.

PubMed

Kabbasch, C; Dorn, F; Wenchel, H M; Krug, B; Mpotsaris, A; Liebig, T

2017-03-01

Bacterial contamination during angiographic procedures is a potential source of bacteremia. It is largely unknown whether it is clinically relevant. Our aim was to evaluate the incidence of contamination of liquids during catheter-based neuroangiographic examinations, the spectrum of microorganisms, a comparison of two different trolley-settings, and a follow-up of all patients with regard to clinical and lab signs of infection. A total of 170 patients underwent either diagnostic angiography (n = 111) or arterial neuroendovascular procedures (n = 59). To study the impact of airborne contamination of sterile liquids, we randomly assigned equal numbers of procedures to two distinct setups. Group A with standard open-surface bowls and group B with repetitive coverage of liquids throughout the procedure. Patient preparation was performed with utmost care. After each procedure, samples of the liquids were sent for microbiological evaluation. Patients were followed for signs of infection (fever, white blood cell count, C-reactive-protein). Of all samples, 25.3 % were contaminated. Contamination consisted of resident skin microbiota only and was more common with procedures (28.8 %) than with diagnostic angiography (23.4 %) and less common in uncovered (23.5 %) than in covered bowls (27.1 %). However, these differences were insignificant. None of the patients developed clinical or lab signs of infection. Contamination during diagnostic and interventional angiography does occur and cannot be avoided by intermittent coverage. Despite a surprisingly high incidence, our findings support the common strategy that antibiotic coverage is unnecessary in most patients undergoing arterial angiography as it lacks clinical impact. Airborne contamination does not appear to play a role.

Development of new malaria diagnostics: matching performance and need.

PubMed

Bell, David; Fleurent, Alessandra E; Hegg, Michael C; Boomgard, John D; McConnico, Caitlin C

2016-08-11

Despite advances in diagnostic technology, significant gaps remain in access to malaria diagnosis. Accurate diagnosis and misdiagnosis leads to unnecessary waste of resources, poor disease management, and contributes to a cycle of poverty in low-resourced communities. Despite much effort and investment, few new technologies have reached the field in the last 30 years aside from lateral flow assays. This suggests that much diagnostic development effort has been misdirected, and/or that there are fundamental blocks to introduction of new technologies. Malaria diagnosis is a difficult market; resources are broadly donor-dependent, health systems in endemic countries are frequently weak, and the epidemiology of malaria and priorities of malaria programmes and donors are evolving. Success in diagnostic development will require a good understanding of programme gaps, and the sustainability of markets to address them. Targeting assay development to such clearly defined market requirements will improve the outcomes of product development funding. Six market segments are identified: (1) case management in low-resourced countries, (2) parasite screening for low density infections in elimination programmes, (3) surveillance for evidence of continued transmission, (4) clinical research and therapeutic efficacy monitoring, (5) cross-checking for microscopy quality control, and (6) returned traveller markets distinguished primarily by resource availability. While each of these markets is potentially compelling from a public health standpoint, size and scale are highly variable and continue to evolve. Consequently, return on investment in research and development may be limited, highlighting the need for potentially significant donor involvement or the introduction of novel business models to overcome prohibitive economics. Given the rather specific applications, a well-defined set of stakeholders will need to be on board for the successful introduction and scaling of any new technology to these markets.

Evaluation of Human Research Facility Ultrasound With the ISS Video System

NASA Technical Reports Server (NTRS)

Melton, Shannon; Sargsyan, Ashot

2003-01-01

Most medical equipment on the International Space Station (ISS) is manifested as part of the U.S. or the Russian medical hardware systems. However, certain medical hardware is also available as part of the Human Research Facility. The HRF and the JSC Medical Operations Branch established a Memorandum of Agreement for joint use of certain medical hardware, including the HRF ultrasound system, the only diagnostic imaging device currently manifested to fly on ISS. The outcome of a medical contingency may be changed drastically, or an unnecessary evacuation may be prevented, if clinical decisions are supported by timely and objective diagnostic information. In many higher-probability medical scenarios, diagnostic ultrasound is a first-choice modality or provides significant diagnostic information. Accordingly, the Clinical Care Capability Development Project is evaluating the HRF ultrasound system for its utility in relevant clinical situations on board ISS. For effective management of these ultrasound-supported ISS medical scenarios, the resulting data should be available for viewing and interpretation on the ground, and bidirectional voice communication should be readily available to allow ground experts (sonographers, physicians) to provide guidance to the Crew Medical Officer. It may also be vitally important to have the capability of real-time guidance via video uplink to the CMO-operator during an exam to facilitate the diagnosis in a timely fashion. In this document, we strove to verify that the HRF ultrasound video output is compatible with the ISS video system, identify ISS video system field rates and resolutions that are acceptable for varying clinical scenaiios, and evaluate the HRF ultrasound video with a commercial, off-the-shelf video converter, and compare it with the ISS video system.

Doing Pre-operative Investigations in Emergency Department; a Clinical Audit.

PubMed

Rafiq, Muhammad Salman; Rafiq, Maria; Rafiq, Muhammad Imran; Salman, Seema Gul; Hafeez, Sania

2017-01-01

Pre-operative investigations for emergency surgical patients differ between centers. Following established guidelines can reduce unnecessary investigation, cost of treatment and hospital stay. The present audit was carried out to evaluate the condition of doing pre-operative investigations for three common surgical emergencies compared to National Institute for Health and Care Excellence (NICE) guidelines and local criteria. A retrospective clinical audit of acute-appendicitis, abscess and hernia patients admitted to the emergency department was carried out over a one-year period from July 2014 to July 2015. Data of laboratory investigations, their indication, cost and duration of hospital stay was collected and compared with NICE-guidelines. A total of 201 patients were admitted to the emergency department during the audit period. These included 77(38.3%) cases of acute-appendicitis, 112 (55.7%) cases of abscesses, and 12 (6%) cases of hernia. Investigations not indicated by NICE-guidelines included 42 (20.9%) full blood counts, 29 (14.4%) random blood sugars, 26 (12.9%) urea tests, 4 (2%) chest x-rays, 13 (6.5%) electrocardiographs, and 58 (28.9%) urine analyses. These cost 25,675 Rupees (245.46 Dollars) in unnecessary investigation costs and 65.7 days of additional hospital stay. Unnecessary investigations for emergency surgical patients can be reduced by following NICE-guidelines. This will reduce workload on emergency services, treatment costs and the length of hospital stay.

Rapid viral diagnosis of acute respiratory infections: comparison of enzyme-linked immunosorbent assay and the immunofluorescence technique for detection of viral antigens in nasopharyngeal secretions.

PubMed Central

Grandien, M; Pettersson, C A; Gardner, P S; Linde, A; Stanton, A

1985-01-01

Nasopharyngeal secretions from adults and children were obtained in Stockholm, Sweden, for routine diagnosis of influenza A virus, influenza B virus, respiratory syncytial (RS) virus, parainfluenza type 3 virus, and adenovirus infections by demonstration of viral antigens directly in the specimens. The cells in nasopharyngeal secretions were pelleted by centrifugation for preparation of cell deposits for diagnosis by the immunofluorescence technique (IF) in London, England, and in Stockholm, whereas the supernatants were used to diagnose infection by the enzyme-linked immunosorbent assay (ELISA) in Stockholm. Titrations of the various purified viruses showed that ELISA could detect viral antigens in amounts corresponding to 1 to 10 ng of virus protein per test well. In a series of 73 specimens tested for influenza A, RS, and parainfluenza type 3 viruses by IF in London and by ELISA in Stockholm, 15 of 18 RS, 14 of 15 influenza A, and 2 of 2 parainfluenza type 3 viral infections were diagnosed by ELISA as compared with IF, giving sensitivities for RS and influenza A viral diagnosis of 83 and 93%, respectively, and a specificity of 100%. In another series of specimens from 35 patients tested for influenza B virus and adenovirus, five influenza B virus and four adenovirus infections were diagnosed by both methods; one additional influenza B infection was detected only by IF and another only by ELISA. Comparisons of diagnostic results between the two methods performed in Stockholm gave nonagreement of results for 37 of 1,593 tests (2.5%) for the five viruses. The conclusion reached was that the described ELISA, although a satisfactory test, had somewhat less sensitivity than did IF for the detection of respiratory viral infections. This could possibly be explained by unnecessary dilutions of specimens at the time of collection; transportation, processing, and storage of specimens were less complicated than for IF. PMID:2997270

High-throughput, non-invasive prenatal testing for fetal Rhesus D genotype to guide antenatal prophylaxis with anti-D immunoglobulin: a cost-effectiveness analysis.

PubMed

Saramago, P; Yang, H; Llewellyn, A; Palmer, S; Simmonds, M; Griffin, S

2018-02-07

To evaluate the cost-effectiveness of high-throughput, non-invasive prenatal testing (HT-NIPT) for fetal Rhesus D (RhD) genotype to guide antenatal prophylaxis with anti-D immunoglobulin compared with routine antenatal anti-D immunoglobulin prophylaxis (RAADP). Cost-effectiveness decision-analytic modelling. Primary care. A simulated population of 100 000 RhD-negative women not known to be sensitised to the RhD antigen. A decision tree model was used to characterise the antenatal care pathway in England and the long-term consequences of sensitisation events. The diagnostic accuracy of HT-NIPT was derived from a systematic review and bivariate meta-analysis; estimates of other inputs were derived from relevant literature sources and databases. Women in whom the HT-NIPT was positive or inconclusive continued to receive RAADP, whereas women with a negative result received none. Five alternative strategies in which the use of HT-NIPT may affect the existing postpartum care pathway were considered. Costs expressed in 2015GBP and impact on health outcomes expressed in terms of quality-adjusted life-years over a lifetime. The results suggested that HT-NIPT appears cost saving but also less effective than current practice, irrespective of the postpartum strategy evaluated. A postpartum strategy in which inconclusive test results are distinguished from positive results performed best. HT-NIPT is only cost-effective when the overall test cost is £26.60 or less. HT-NIPT would reduce unnecessary treatment with routine anti-D immunoglobulin and is cost saving when compared with current practice. The extent of any savings and cost-effectiveness is sensitive to the overall test cost. HT-NIPT is cost saving compared with providing anti-D to all RhD-negative pregnant women. © 2018 Royal College of Obstetricians and Gynaecologists.

Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance.

PubMed

Heller, Michael; Zanocco, Kyle; Zydowicz, Sara; Elaraj, Dina; Nayar, Ritu; Sturgeon, Cord

2012-09-01

The 2007 National Cancer Institute (NCI) conference on Thyroid Fine-Needle Aspiration (FNA) introduced the category atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS). Repeat FNA in 3 to 6 months was recommended for low-risk patients. Compliance with these recommendations has been suboptimal. We hypothesized that repeat FNA would be more effective than diagnostic lobectomy, with decreased costs and improved rates of cancer detection. Cost-effectiveness analysis was performed in which we compared diagnostic lobectomy with repeat FNA. A Markov model was developed. Outcomes and probabilities were identified from literature review. Third-party payer costs were estimated in 2010 US dollars. Outcomes were weighted by use of the quality-of-life utility factors, yielding quality-adjusted life years (QALYs). Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost, and utility estimates. The diagnostic lobectomy strategy cost $8,057 and produced 23.99 QALYs. Repeat FNA cost $2,462 and produced 24.05 QALYs. Repeat FNA was dominant until the cost of FNA increased to $6,091. Dominance of the repeat FNA strategy was not sensitive to the cost of operation or the complication rate. The NCI recommendations for repeat FNA regarding follow-up of AUS/FLUS results are cost-effective. Improving compliance with these guidelines should lead to less overall costs, greater quality of life, and fewer unnecessary operations. Copyright © 2012 Mosby, Inc. All rights reserved.

Screening for genital tuberculosis in a limited resource country: case report.

PubMed

Namani, Sadie; Qehaja-Buçaj, Emine; Namani, Diellëza

2017-02-07

Screening for benign or malignant process of pelvis in young females is a challenge for a physician in a limited resource country. Tuberculosis should be always considered in the differential diagnosis of a pelvic mass in countries with high prevalence of tuberculosis. Negative results of analysis of peritoneal fluid for acid-fast staining, late cultures, and unavailability of new diagnostics methods such as polymerase chain reaction and adenosine deaminase of the aspirated fluid from peritoneal cavity can often result in invasive diagnostic procedures such as laparotomy. We report a case of a 24 year old Albanian unemployed female living in urban place in Kosovo who presented with abdominal pain, loss of appetite, fever, headache, a weight loss, nonproductive cough and menstrual irregularity for three weeks. In this example case, the patient with cystic mass in tubo-ovarial complex and elevated serum cancer antigen 125 levels was diagnosed for genital tuberculosis after performing laparotomy. Caseose mass found in left tubo-ovarial complex and histopathological examination of biopsied tissue were the fastest diagnostic tools for confirming pelvis TB. The Lowenstein-Jensen cultures were positive after six weeks and her family history was positive for tuberculosis. Young females with abdominopelvic mass, ascites, a positive family history for tuberculosis and high serum cancer antigen 125, should always raise suspicion of tuberculosis especially in a limited resource country. A laparoscopy combined with peritoneal biopsy should be performed to confirm the diagnosis as this could lead to a prevention of unnecessary laparotomies.