RESUMO
OBJECTIVES: In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach. METHODS: A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed. RESULTS: The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student's differential diagnosis was also compared. Comparison of proportions were conducted using χ2-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (ß=0.37, p<0.001) and 17% respectively (ß=0.45, p<0.001). CONCLUSIONS: The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.
Assuntos
Internato e Residência , Estudantes de Medicina , Competência Clínica , Simulação por Computador , Humanos , Resolução de ProblemasRESUMO
PURPOSE: The first aim of the study was to determine whether (99m)Tc-HYNIC-annexin V, a marker of cellular stress and apoptosis, can detect ischemic injury in patients with acute stroke. Secondly, we wished to test radiolabeled annexin's ability to monitor therapy in a rodent model of focal ischemic injury. METHODS: SPECT imaging of patients was performed between 1 and 2 h after intravenous injection of 30 mCi (1,110 MBq) of tracer. Eight MFL4 (anti-FasL) antibody-treated (400 microg i.p. days 0 and 3) and 21 control adult male Sprague-Dawley rats underwent small animal SPECT imaging with 5-10 mCi (185-370 MBq) of tracer, 1 and 6 days after a 2-h intraluminal thread occlusion of the left middle cerebral artery. RESULTS: Two patients with acute stroke had regions of multifocal annexin uptake that correlated with sites of restricted diffusion on MRI. Anti-FasL antibody treatment significantly reduced annexin uptake by 92% with a 60% decrease in the number of caspase-8 staining (apoptotic) neurons on day 1. On day 6, treated animals had an 80% reduction in tracer uptake with a 75% decrease in infarct size as compared with controls. Annexin uptake in controls and treated animals (day 6) linearly correlated with infarct size (r (2)=0.603, p=0.0036) and the number of TUNEL-positive (apoptotic) nuclei (r (2)=0.728, p=0.00084). CONCLUSION: Annexin imaging shows foci of increased uptake at sites of ischemic injury in patients with acute stroke. Annexin imaging can assess the effects of therapy for ischemic cerebral injury in rats, suggesting its potential as a non-invasive indicator of drug efficacy in future clinical trials.
Assuntos
Anexina A5 , Anticorpos Monoclonais/uso terapêutico , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Compostos de Organotecnécio , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Doença Aguda , Animais , Anticorpos Monoclonais Murinos , Isquemia Encefálica/etiologia , Humanos , Masculino , Fármacos Neuroprotetores/uso terapêutico , Prognóstico , Compostos Radiofarmacêuticos , Ratos , Ratos Sprague-Dawley , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Acidente Vascular Cerebral/complicações , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Resultado do TratamentoAssuntos
Radioisótopos do Iodo/efeitos adversos , Lesões por Radiação/etiologia , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/efeitos da radiação , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Contagem Corporal Total/efeitos adversos , Ensaios Clínicos como Assunto , Medicina Baseada em Evidências , Humanos , Radioisótopos do Iodo/uso terapêutico , Lesões por Radiação/prevenção & controle , Cintilografia , Compostos Radiofarmacêuticos/efeitos adversos , Compostos Radiofarmacêuticos/uso terapêutico , Neoplasias da Glândula Tireoide/radioterapia , Neoplasias da Glândula Tireoide/cirurgia , Resultado do Tratamento , Contagem Corporal Total/métodosRESUMO
The outcome in differentiated thyroid cancer is excellent. Simple prognostic factors, including the age of the patient at diagnosis, the size of the primary cancer, completeness of surgical excision, and the presence of distant metastases, allow the clinician to judge how a patient will do. The preferred treatment is total thyroidectomy and in selected patients radioactive iodine can be used to ablate residual thyroid or functioning metastases in lymph nodes and distant sites. The physician has two excellent methods for following the patient: the whole-body scan with radionuclides of iodine, and measurement of serum thyroglobulin. In patients with elevated thyroglobulin and negative scans with radioactive iodine, there is increasing evidence that positron emission tomography (PET) is helpful in locating the site of thyroglobulin production.