Segunda opinião diagnóstica na anatomia patológica / Second opinion on pathological anatomy

A anatomia patológica, veterinária e humana, no contexto mundial, adota, com cada vez mais frequência, a prática de segunda opinião diagnóstica, como método de verificação e confirmação de pareceres técnicos, objetivando uma maior acurácia e precisão dos diagnósticos fornecidos. Este trabalho tem por objetivo discorrer sobre a importância da segunda opinião diagnóstica na anatomia patológica e seus aspectos éticos. A segunda opinião reflete uma medida de precisão diagnóstica e, apesar de alguns sítios anatômicos ou áreas de subespecialidade apresentarem maiores frequências de grandes discordâncias diagnósticas, quase todas as áreas no âmbito da anatomia patológica podem ser clinicamente afetadas pela segunda opinião. Dadas as variações entre as instituições, recomenda-se a revisão de segunda opinião de todos os locais anatômicos em todas as instituições, públicas e privadas, para maximizar a descoberta de divergências clinicamente relevantes.

Human and veterinary medicine pathological Anatomy in the world context, increasingly adopts the practice of second diagnostic opinion, as a method of verification and confirmation of technical opinions, aiming at greater accuracy and precision of the diagnoses provided. This work aims to discuss the importance of the second diagnostic opinion in pathological anatomy and its ethical aspects. The second opinion reflects a measure of diagnostic accuracy, and although some anatomical sites or areas of subspecialty have higher frequencies of major diagnostic disagreements, almost all areas within the pathological anatomy can be clinically affected by the second opinion. Given the variations between institutions, a second opinion review of all anatomic sites in all institutions, public and private, is recommended to maximize the discovery of clinically relevant discrepancies.

Covert cases of Severe Acute Respiratory Syndrome Coronavirus 2: An obscure but present danger in regions endemic for Dengue and Chikungunya viruses.

BACKGROUND: The impact of SARS-CoV-2 in regions endemic for both Dengue and Chikungunya is still not fully understood. Considering that symptoms/clinical features displayed during Dengue, Chikungunya and SARS-CoV-2 acute infections are similar, undiagnosed cases of SARS-CoV-2 in co-endemic areas may be more prevalent than expected. This study was conducted to assess the prevalence of covert cases of SARS-CoV-2 among samples from patients with clinical symptoms compatible with either Dengue or Chikungunya viral infection in the state of Espírito Santo, Brazil. METHODS: Presence of immunoglobulin G (IgG) antibody specific to SARS-CoV-2 nucleoprotein was detected using a chemiluminescent microparticle immunoassay in samples from 7,370 patients, without previous history of COVID-19 diagnosis, suspected of having either Dengue (n = 1,700) or Chikungunya (n = 7,349) from December 1st, 2019 to June 30th, 2020. FINDINGS: Covert cases of SARS-CoV-2 were detected in 210 (2.85%) out of the 7,370 serum samples tested. The earliest undiagnosed missed case of COVID-19 dated back to a sample collected on December 18, 2019, also positive for Dengue Virus. Cross-reactivity with either Dengue virus or other common coronaviruses were not observed. INTERPRETATION: Our findings demonstrate that concomitant Dengue or Chikungunya outbreaks may difficult the diagnosis of SARS-CoV-2 infections. To our knowledge, this is the first study to demonstrate, with a robust sample size (n = 7,370) and using highly specific and sensitive chemiluminescent microparticle immunoassay method, that covert SARS-CoV-2 infections are more frequent than previously expected in Dengue and Chikungunya hyperendemic regions. Moreover, our results suggest that SAR-CoV-2 cases were occurring prior to February, 2020, and that these undiagnosed missed cases may have contributed to the fast expansion of SARS-CoV-2 outbreak in Brazil. Data presented here demonstrate that in arboviral endemic regions, SARS-CoV-2 infection must be always considered, regardless of the existence of a previous positive diagnosis for Dengue or Chikungunya.

Errores de medición en la interpretación mamográfica por radiólogos / Measurements errors in screening mammogram interpretation by radiologists

RESUMEN La detección oportuna de cáncer de mama se realiza mediante mamografía; sin embargo, se debe prestar atención a la calidad de la misma para su realización e interpretación. A pesar de recientes mejoras en el control de calidad de la mamografía, la interpretación todavía depende de cada lector; por lo que se pueden cometer errores en la interpretación mamográfica y éstos pueden producir biopsias no necesarias y/o sobre-diagnóstico, reportándose consecuencias físicas, económicas y psicológicas sostenidas; debido a que la interpretación obedece a la habilidad perceptiva y cognitiva del médico radiólogo. Sin embargo, se requiere de un amplio conocimiento de los posibles errores que puede haber en la interpretación de mamografías, y la forma en que pueden minimizarse, prevenirse y/o corregirse con el fin de ofrecer a la paciente la mayor seguridad posible.(AU)

ABSTRACT The timely detection of breast cancer is achieved through mammography; however, the quality of the procedure should be addressed for proper performance and interpretation. Despite recent improvements in quality assurance in mammography, interpretation still depends on each reader; therefore, errors can be made when interpreting screening mammograms, leading to unnecessary biopsies and/or overdiagnosis, with sustained physical, economic and psychological consequences. Since interpretation is related to the perceptive and cognitive ability of the radiologist, it is necessary to have extensive knowledge about the possible errors that may occur during interpretation, as well as of the way how they can be reduced, prevented and/or corrected to provide the patient with the highest possible level of safety.(AU)

Error en el informe radiológico: la paradoja del elefante en la habitación y otros tropiezos / Error in the radiological report: the paradox of the elephant in the room and other mistakes

The expression "there is an elephant in the room" refers to an obvious problem that goes unnoticed. Often we wonder how it was possible that we have not reported a major lesion ("the size of an elephant") in the report that comes into our hands for review. Unlike clinical findings such as the anamnesis and the physical examination, evidence from the radiological examination remains available for subsequent reviews. The error and its consequences are a phenomenon that vertically and horizontally traverse all the medical specialties and those who perform within them. Radiologists are not exempt from this. During each stage of the reporting process, the radiologist may make mistakes. In this article we will concentrate on those errors in which the radiologist participates directly, with graphical representations that illustrate the nature of the error in each case. We will review the phases of the imaging diagnosis and the different types of errors such as Perceptual Errors (error by under-reading, search satisfaction errors, and error due to alterations outside the study area), Cognitive errors (complacency error, error of reasoning, alliterative error, error due to lack of knowledge, error due to lack of clinical records and error due to lack of consultation of previous examinations), Communication error and study type error. Because we cannot completely eliminate the diagnostic errors in our daily practice, we cannot guarantee the outcome; but we can demonstrate that we have done our best, with duly justified technical quality examinations, in the adequate time and with the necessary security.

La expresión "hay un elefante en la habitación", se refiere a que existe un problema obvio que pasa inadvertido. Muchas veces nos preguntamos cómo fue posible que no hayamos reportado una gran lesión ("del tamaño de un elefante") en el informe que llega a nuestras manos para revisión. A diferencia de los hallazgos clínicos como la anamnesis y el examen físico, la evidencia del examen radiológico permanece disponible para revisiones subsecuentes. El error y sus consecuencias son un fenómeno que cruza vertical y horizontalmente todas las especialidades médicas y a quienes en ellas se desempeñan. Los radiólogos no estamos exentos de ello. Durante cada etapa del proceso de informe, el médico radiólogo puede cometer errores. En este artículo nos concentraremos en aquellos errores en los que el radiólogo participa directamente, con representaciones gráficas que ilustran la naturaleza del error en cada caso. Revisaremos las fases del diagnóstico por imágenes y los diferentes tipos de errores como los Errores de percepción (error por sub-lectura, error por satisfacción de la búsqueda y error debido a alteraciones fuera del área de estudio), Errores cognitivos (error de complacencia, error de razonamiento, error aliterativo, error por falta de conocimientos, error por falta de antecedentes clínicos y error por falta de consulta de exámenes previos), Error de comunicación y Error de tipo de estudio. Debido a que no podemos eliminar completamente los errores diagnósticos en nuestra práctica diaria, no podemos garantizar el resultado; pero podemos demostrar que hicimos lo mejor posible, con exámenes de calidad técnica, debidamente justificados, en el tiempo adecuado y con la seguridad necesaria.

Advanced radiologic imaging for pediatric appendicitis, 2005-2009: trends and outcomes.

OBJECTIVES: To examine the variability in the use of computed tomography (CT) and ultrasound (US) for children with appendicitis and identify associations with clinical outcomes, and to demonstrate any trends in diagnostic imaging between 2005 and 2009. STUDY DESIGN: This was a retrospective review of children evaluated for appendicitis in an emergency department between 2005 and 2009 using an administrative database of 40 pediatric institutions in the United States. Imaging utilization by institutions was studied for association with 3 clinical outcomes. RESULTS: A total of 55 238 children with appendicitis were studied. Utilization of CT and US varied widely across institutions, with medians of 34% (IQR, 21%-49%) for CT and 6% (IQR, 2%-26%) for US. Increased use of US or a combination of CT and US (but not of CT use alone) was associated with a lower negative appendectomy rate. Imaging was not associated with other clinical outcomes. In children with appendicitis, the use of US has increased since 2007, whereas that of CT has decreased. CONCLUSION: There is considerable variation in the use of CT and US for children with appendicitis at major pediatric institutions. At the institutional level, increased use of US or combined US and CT is associated with a lower negative appendectomy rate. Despite the better diagnostic accuracy of CT compared with US, the use of CT is decreasing.

Evitando erros na interpretação da radiologia torácica: dez passos para melhorar sua acurácia diagnóstica / Avoiding errors in thoracic radiology interpretation: ten steps to improve your diagnostic accuracy / Cómo evitar errores en la interpretación de la radiología torácica: diez pasos para mejorar su precisión diagnóstica

O exame radiográfico torácico pode ser um desafio para os radiologistas veterinários, principalmente os iniciantes. Muitas são as armadilhas que podem ocorrer durante a interpretação dos exames radiográficos dessa região em cães e gatos, e com isso a apreensão de se perder uma lesão é frequente na prática clínica-radiográfica. Ressalta-se, portanto, a importância do conhecimento dos fatores que podem gerar dificuldades de interpretação como: posicionamento inadequado, influência da técnica utilizada, preparo e processamento do filme radiográfico, o conhecimento das variações de idade, raça, espécie e da característica física do paciente, bem como efeitos de somação. Nesse arti go objetivamos discutir, em forma de tópicos, os fatores que podem influenciar ou dificultar a boa interpretação de filmes radiográficos torácicos em pequenos animais.(AU)

Thoracic radiographics can be a challenge for veterinary radiologists, especially for beginners. Many misunderstandings can occur during the interpretation of the thorax radiographic exam of dogs and cats, which leads to apprehension about missing a lesion. It is therefore important to know which factors may cause interpretation difficulties, such as improper positioning, influence of the used technique, addition effects, preparation and processing of the radiographic film, knowledge about age-related variations, as well as those related to breed, species and physical properties of the patient. In this paper we aim to discuss topics such as the factors and difficulties that can influence the correct interpretation of thoracic radiographics of small animals.(AU)

El examen radiográfico del tórax puede representar un desafío para los radiólogos veterinarios, más aún para aquellos que están comenzando en la especialidad. El médico actuante puede encontrar situaciones confusas durante la interpretación de las radiografías de esa región en perros y gatos, y de esa forma poder no llegar a identificar algunas lesiones en la práctica clínica y radiográfica. Por consiguiente, debe ser destacada la importancia de conocer los factores que pueden causar dificultades de interpretación, como por ejemplo: el posicionamiento inadecuado, la técnica utilizada, la preparación y procesamiento de la película radiográfica, el conocimiento de las variaciones de edad, raza, especie y características físicas del paciente, así como los efectos de la suma de los factores antes nombrados. En este artículo el objetivo es analizar, a través de tópicos, los factores que pueden influir o dificultar la correcta interpretación de las radiografías de tórax de pequeños animales.(AU)

Evitando erros na interpretação da radiologia torácica: dez passos para melhorar sua acurácia diagnóstica / Avoiding errors in thoracic radiology interpretation: ten steps to improve your diagnostic accuracy / Cómo evitar errores en la interpretación de la radiología torácica: diez pasos para mejorar su precisión diagnóstica

O exame radiográfico torácico pode ser um desafio para os radiologistas veterinários, principalmente os iniciantes. Muitas são as armadilhas que podem ocorrer durante a interpretação dos exames radiográficos dessa região em cães e gatos, e com isso a apreensão de se perder uma lesão é frequente na prática clínica-radiográfica. Ressalta-se, portanto, a importância do conhecimento dos fatores que podem gerar dificuldades de interpretação como: posicionamento inadequado, influência da técnica utilizada, preparo e processamento do filme radiográfico, o conhecimento das variações de idade, raça, espécie e da característica física do paciente, bem como efeitos de somação. Nesse arti go objetivamos discutir, em forma de tópicos, os fatores que podem influenciar ou dificultar a boa interpretação de filmes radiográficos torácicos em pequenos animais.

Thoracic radiographics can be a challenge for veterinary radiologists, especially for beginners. Many misunderstandings can occur during the interpretation of the thorax radiographic exam of dogs and cats, which leads to apprehension about missing a lesion. It is therefore important to know which factors may cause interpretation difficulties, such as improper positioning, influence of the used technique, addition effects, preparation and processing of the radiographic film, knowledge about age-related variations, as well as those related to breed, species and physical properties of the patient. In this paper we aim to discuss topics such as the factors and difficulties that can influence the correct interpretation of thoracic radiographics of small animals.

El examen radiográfico del tórax puede representar un desafío para los radiólogos veterinarios, más aún para aquellos que están comenzando en la especialidad. El médico actuante puede encontrar situaciones confusas durante la interpretación de las radiografías de esa región en perros y gatos, y de esa forma poder no llegar a identificar algunas lesiones en la práctica clínica y radiográfica. Por consiguiente, debe ser destacada la importancia de conocer los factores que pueden causar dificultades de interpretación, como por ejemplo: el posicionamiento inadecuado, la técnica utilizada, la preparación y procesamiento de la película radiográfica, el conocimiento de las variaciones de edad, raza, especie y características físicas del paciente, así como los efectos de la suma de los factores antes nombrados. En este artículo el objetivo es analizar, a través de tópicos, los factores que pueden influir o dificultar la correcta interpretación de las radiografías de tórax de pequeños animales.

Ameloblastoma: consequências de um caso mal diagnosticado / Ameloblastoma: consequences of a misdiagnosed case

O presente relato descreve um caso de ameloblastoma ocorrido em região de incisivos inferiores, diagnosticado, erroneamente como alteração periapical de origem endodôntica e periodontal. O paciente foi tratado por um período de 4 anos, durante o qual não foi observada a regressão da lesão. Quando o paciente foi encaminhado para a clínica de Estomatologia da Faculdade de Odontologia da Universidade Federal de Minas Gerais, através dos examens clínico, radiográfico e biópsia incisional, a lesão foi diagnosticada como ameloblastoma. O paciente foi submetido à cirurgia de ressecção parcial em bloco da mandíbula. O caso expõe a mutilação extensa ocorrida com conseqüência de um equívoco no diagnóstico inicial.

External quality assurance for cervical cytology in developing countries. Experience in Peru and Nicaragua.

Given interest from the professionals concerned, an external quality assurance scheme for cervical cytology can successfully be introduced in developing countries. This is a very important precondition if screening programs are to be expanded and decreases in mortality from cervical cancer are to occur in developing countries. Nicaragua and Peru have been experimenting with an external quality assurance system adapted from the Scottish and Northern Ireland scheme. It has been received with enthusiasm and acceptance and has helped cytology laboratories in these countries focusing on quality issues. Nevertheless, a successful quality control scheme that is to result in improvements in the quality of professionals' diagnostic skills needs to be accompanied by a remedial program for subperformers.