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1.
J Med Case Rep ; 15(1): 111, 2021 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-33653404

RESUMO

BACKGROUND: Most sudden-onset hearing loss is due to otolaryngologic- and very rarely to cerebrovascular disease. We report a woman with sudden bilateral sensorineural hearing loss. This case suggests that even in the absence of brainstem or cerebellar signs, magnetic resonance imaging (MRI) and MR angiography (MRA) should be performed since such studies may reveal signs of life-threatening vertebrobasilar artery occlusion. CASE PRESENTATION: A 73-year-old Japanese woman with a history of hypertension, hyperlipidemia, and atrial fibrillation who suffered bilateral deafness with vertigo and vomiting was transferred from a local hospital to our department. On admission her consciousness was clear and vertigo was absent. Neurological examination revealed only bilateral sensorineural hearing loss. Head computed tomography (CT) returned no significant findings. The next morning she gradually developed severe drowsiness. Diffusion-weighted MRI demonstrated acute cerebral infarction in the brainstem and bilateral cerebellum; MRA showed basilar artery occlusion due to a cardioembolic thrombus. Revascularization was obtained by endovascular treatment. However, her condition worsened progressively during the following hours. CT revealed new brainstem lesions, massive cerebellar swelling, and obstructive hydrocephalus. She died on the second day after her admission. CONCLUSIONS: When hearing loss is due to vertebrobasilar occlusive disease, the prognosis is very poor. We suggest that vertebrobasilar stroke be suspected in patients with bilateral sensorineural hearing loss who present with risk factors for stroke such as atrial fibrillation and other neurologic signs.


Assuntos
Infartos do Tronco Encefálico/complicações , Doenças Cerebelares/complicações , Perda Auditiva Bilateral/etiologia , Perda Auditiva Súbita/etiologia , Diagnóstico Ausente , Insuficiência Vertebrobasilar/complicações , Idoso , Fibrilação Atrial/complicações , Artéria Basilar/diagnóstico por imagem , Infartos do Tronco Encefálico/diagnóstico por imagem , Doenças Cerebelares/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Hiperlipidemias/complicações , Hipertensão/complicações , Angiografia por Ressonância Magnética , Imagem por Ressonância Magnética , Artéria Vertebral/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico por imagem
2.
BMJ Case Rep ; 14(1)2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33431451

RESUMO

We present a case of volar rotatory subluxation of index finger proximal interphalangeal joint (PIPJ) following a skiing accident. The injury was initially perceived to be a central slip rupture and treatment was directed as such. After the initial delay in the diagnosis, the patient underwent surgery during which his radial collateral ligament was found to be avulsed from the proximal origin, the radial lateral band palmarly subluxed and was interposed in the joint space. This structure was also adhered to the uninjured volar plate.PIPJ volar rotatory subluxation could be readily missed in the acute setting. Without surgery, the functional outcome could be mediocre and to the patient's detriment.


Assuntos
Ligamentos Colaterais/lesões , Traumatismos dos Dedos/diagnóstico , Luxações Articulares/diagnóstico , Esqui/lesões , Adulto , Ligamentos Colaterais/diagnóstico por imagem , Ligamentos Colaterais/patologia , Ligamentos Colaterais/cirurgia , Diagnóstico Tardio , Traumatismos dos Dedos/etiologia , Traumatismos dos Dedos/cirurgia , Articulações dos Dedos/diagnóstico por imagem , Articulações dos Dedos/patologia , Articulações dos Dedos/cirurgia , Humanos , Período Intraoperatório , Luxações Articulares/etiologia , Luxações Articulares/cirurgia , Masculino , Diagnóstico Ausente , Placa Palmar/diagnóstico por imagem , Placa Palmar/patologia , Placa Palmar/cirurgia , Amplitude de Movimento Articular , Fatores de Tempo , Aderências Teciduais/diagnóstico , Aderências Teciduais/etiologia , Aderências Teciduais/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
3.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509859

RESUMO

A high functioning 74-year-old man with systemic lupus erythematosus presented to the emergency department with acute anxiety. He was found to have elevated cardiac enzymes and admitted to the cardiology service for investigation. In hospital, he developed an erythematous papular rash, and deteriorated to being somnolent and bedridden. He was found to have new multiterritory ischaemic strokes. It was eventually noted that he had persistent eosinophilia, present even on admission, which had been overlooked as the total leucocyte count was normal. Serology for antiphospholipid antibody syndrome (APS) was positive. He was diagnosed with hypereosinophilic syndrome (HES) secondary to new APS, and responded to high-dose steroids. This case highlights the importance of fully evaluating a leucocyte differential to make a diagnosis of HES. We discuss the definition, clinical manifestations, diagnostic approach and management of this important condition.


Assuntos
Síndrome Antifosfolipídica/diagnóstico , Cardiomiopatias/diagnóstico , Síndrome Hipereosinofílica/diagnóstico , Diagnóstico Ausente , Idoso , Síndrome Antifosfolipídica/complicações , Síndrome Antifosfolipídica/tratamento farmacológico , Síndrome Antifosfolipídica/fisiopatologia , Cardiomiopatias/sangue , Cardiomiopatias/tratamento farmacológico , Cardiomiopatias/etiologia , Creatina Quinase/sangue , Estado Terminal , Exantema/etiologia , Glucocorticoides/uso terapêutico , Humanos , Síndrome Hipereosinofílica/tratamento farmacológico , Síndrome Hipereosinofílica/etiologia , Síndrome Hipereosinofílica/fisiopatologia , Imunossupressores/uso terapêutico , Contagem de Leucócitos , Lúpus Eritematoso Sistêmico/complicações , Imagem por Ressonância Magnética , Masculino , Paresia/etiologia , Sonolência , Tomografia Computadorizada por Raios X , Troponina/sangue
4.
JMIR Public Health Surveill ; 7(1): e23034, 2021 01 27.
Artigo em Inglês | MEDLINE | ID: mdl-33332282

RESUMO

BACKGROUND: The high prevalence of COVID-19 has resulted in 200,000 deaths as of early 2020. The corresponding mortality rate among different countries and times varies. OBJECTIVE: This study aims to investigate the relationship between the mortality rate and prevalence of COVID-19 within a country. METHODS: We collected data from the Johns Hopkins Coronavirus Resource Center. These data included the daily cumulative death count, recovered count, and confirmed count for each country. This study focused on a total of 36 countries with over 10,000 confirmed COVID-19 cases. Mortality was the main outcome and dependent variable, and it was computed by dividing the number of COVID-19 deaths by the number of confirmed cases. RESULTS: The results of our global panel regression analysis showed that there was a highly significant correlation between prevalence and mortality (ρ=0.8304; P<.001). We found that every increment of 1 confirmed COVID-19 case per 1000 individuals led to a 1.29268% increase in mortality, after controlling for country-specific baseline mortality and time-fixed effects. Over 70% of excess mortality could be attributed to prevalence, and the heterogeneity among countries' mortality-prevalence ratio was significant (P<.001). Further, our results showed that China had an abnormally high and significant mortality-prevalence ratio compared to other countries (P<.001). This unusual deviation in the mortality-prevalence ratio disappeared with the removal of the data that was collected from China after February 17, 2020. It is worth noting that the prevalence of a disease relies on accurate diagnoses and comprehensive surveillance, which can be difficult to achieve due to practical or political concerns. CONCLUSIONS: The association between COVID-19 mortality and prevalence was observed and quantified as the mortality-prevalence ratio. Our results highlight the importance of constraining disease transmission to decrease mortality rates. The comparison of mortality-prevalence ratios between countries can be a powerful method for detecting, or even quantifying, the proportion of individuals with undocumented SARS-CoV-2 infection.


Assuntos
/epidemiologia , Saúde Global/estatística & dados numéricos , Mortalidade/tendências , /mortalidade , Documentação , Humanos , Diagnóstico Ausente , Prevalência
5.
J Surg Res ; 257: 232-238, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32862050

RESUMO

BACKGROUND: The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. RESULTS: There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001). CONCLUSIONS: This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.


Assuntos
Queimaduras/etiologia , Maus-Tratos Infantis/diagnóstico , Criança Hospitalizada/estatística & dados numéricos , Diagnóstico Ausente/estatística & dados numéricos , Adolescente , Queimaduras/terapia , Criança , Maus-Tratos Infantis/prevenção & controle , Maus-Tratos Infantis/estatística & dados numéricos , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Readmissão do Paciente/estatística & dados numéricos , Fatores de Risco , Estados Unidos
7.
PLoS One ; 15(12): e0244004, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33373363

RESUMO

The aim of this paper is to analyze the sequence of actions in the health system associated with a particular disease. In order to do that, using Electronic Health Records, we define a general methodology that allows us to: (i) identify the actions in the health system associated with a disease; (ii) identify those patients with a complete treatment for the disease; (iii) and discover common treatment pathways followed by the patients with a specific diagnosis. The methodology takes into account the characteristics of the EHRs, such as record heterogeneity and missing information. As an example, we use the proposed methodology to analyze breast cancer disease. For this diagnosis, 5 groups of treatments, which fit in with medical practice guidelines and expert knowledge, were obtained.


Assuntos
Neoplasias da Mama/terapia , Gerenciamento de Dados/métodos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/epidemiologia , Confiabilidade dos Dados , Tratamento Farmacológico/estatística & dados numéricos , Registros Eletrônicos de Saúde/normas , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Diagnóstico Ausente , Radioterapia/estatística & dados numéricos
8.
BMJ Case Rep ; 13(12)2020 Dec 22.
Artigo em Inglês | MEDLINE | ID: mdl-33370977

RESUMO

Neuroendocrine neoplasms of the gallbladder occur infrequently, with the diagnosis being incidental in most cases. We present a case of an 81-year-old African American woman who initially presented with acute suppurative cholecystitis, found on pathology to have a moderately differentiated infiltrating adenocarcinoma. A partial hepatic resection with periportal lymph node dissection was planned which was subsequently aborted intraoperatively due to the presence of diffuse carcinomatosis. Pathology of the cancerous lesions revealed neuroendocrine carcinoma. Gallbladder neuroendocrine tumours demonstrate no specific clinical features. Given its often late presentation, neuroendocrine tumours of the gallbladder pose a therapeutic and prognostic challenge.


Assuntos
Carcinoma Neuroendócrino/diagnóstico , Colecistite Aguda/etiologia , Neoplasias da Vesícula Biliar/diagnóstico , Vesícula Biliar/patologia , Neoplasias Peritoneais/diagnóstico , Idoso de 80 Anos ou mais , Carcinoma Neuroendócrino/secundário , Carcinoma Neuroendócrino/terapia , Colecistectomia Laparoscópica , Colecistite Aguda/cirurgia , Evolução Fatal , Feminino , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/complicações , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/terapia , Cuidados Paliativos na Terminalidade da Vida , Humanos , Diagnóstico Ausente , Estadiamento de Neoplasias , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/terapia , Tomografia Computadorizada por Raios X
9.
Medicine (Baltimore) ; 99(42): e22738, 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33080734

RESUMO

BACKGROUND & GOALS: We observed that the number of colorectal polyps found intraoperatively was often higher than that encountered preoperatively during elective colonoscopic polypectomy. To evaluate whether more polyps can be detected when they are purposely sought than when they are routinely examined during colonoscopy. MATERIALS AND METHODS: Patients undergoing colonoscopy were randomized into groups A and B. Before colonoscopy was performed, endoscopists were instructed to seek polyps for group A purposely but not for group B. Polypectomy was electively completed. In groups A and B, the cases of elective polypectomy were named groups AR and BR, including groups AR-1 and BR-1, during the first colonoscopy and groups AR-2 and BR-2 during the second colonoscopy for polypectomy, respectively. The following data were calculated: the number of polyps detected (NPD) and the polyp detection rate (PDR) in all cases and the number of polyps missed (NPM) and partial polyp miss rate (PPMR) in the cases of colorectal polyps. RESULTS: A total of 419 cases were included in group A, 421 in group B, 43 in group AR, and 35 in group BR. No significant differences in PDR were found between groups A and B and in PPMR between groups AR-1 and BR-1 (P > .05), although PPMR in group AR-1 was higher than in group AR-2 (P < .05), similar results were found in PPMR between groups BR-1 and BR-2 (P < .05). CONCLUSION: Purposely seeking for colorectal polyps did not result in more polyps detected compared with routine colonoscopy.


Assuntos
Pólipos do Colo/diagnóstico , Colonoscopia , Pólipos do Colo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diagnóstico Ausente/estatística & dados numéricos , Cuidados Pré-Operatórios
10.
Medicine (Baltimore) ; 99(43): e21518, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120725

RESUMO

RATIONALE: Computer-assisted detection (CAD) systems based on artificial intelligence (AI) using convolutional neural network (CNN) have been successfully used for the diagnosis of unruptured cerebral aneurysms in experimental situations. However, it is yet unclear whether CAD systems can detect cerebral aneurysms effectively in real-life clinical situations. This paper describes the diagnostic efficacy of CAD systems for cerebral aneurysms and the types of cerebral aneurysms that they can detect. PATIENT CONCERNS: From March 7, 2017 to August 26, 2018 we performed brain magnetic resonance imaging (MRI) scans for 1623 subjects, to rule out intracranial diseases. We retrospectively reviewed the medical records including the history and images for each patient. DIAGNOSES, INTERVENTIONS AND OUTCOMES: Among them, we encountered 5 cases in whom the cerebral aneurysms had been overlooked in the first and second round of imaging, and were detected for the first time by CAD. All missed aneurysms were less than 2 mm in diameter. Of the 5 aneurysms, 2 were internal carotid artery (ICA) paraclinoid aneurysms, 2 were Internal carotid-posterior communicating artery (IC-PC) aneurysms and 1 was a distal middle cerebral artery (MCA) aneurysm. LESSONS: Our CAD system can detect very small aneurysms masked by the surrounding arteries and difficult for radiologists to detect. In the future, CAD systems might pave the way to substitute the workload of diagnostic radiologists and reduce the cost of human labor.


Assuntos
Aneurisma Intracraniano/diagnóstico por imagem , Diagnóstico Ausente , Redes Neurais de Computação , Adulto , Idoso , Feminino , Humanos , Imageamento Tridimensional , Achados Incidentais , Angiografia por Ressonância Magnética , Pessoa de Meia-Idade , Estudos Retrospectivos , Software
11.
Medicine (Baltimore) ; 99(43): e22440, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120738

RESUMO

To assess the prevalence and missed reporting rate of potential clinically-significant incidental findings (IFs) in the neck CTA scans.All consecutive patients undergoing neck CTA imaging, from January 1, 2017 to December 31, 2018, were retrospectively evaluated by a radiologist for the presence of incidental findings in the upper chest, lower head and neck regions. These incidental findings were subsequently classified into 3 categories in terms of clinical significance: Type I, highly significant, Type II, moderately significant; and Type III, mildly or not significant. Type I and Type II IFs were determined as potential clinically significant ones and were retrospectively analyzed by another 2 radiologists in consensus. The undiagnosed findings were designated as those that were not reported by the initial radiologists. The differences in the rate of unreported potential clinically significant IFs were compared between the chest group and head or neck group.A total of 376 potential clinically significant IFs were detected in 1,698 (91.19%) patients, of which 175 IFs were classified as highly significant findings (Type I), and 201 (53.46%) as moderately significant findings (Type II). The most common potential clinically significant findings included thyroid nodules (n = 88, 23.40%), pulmonary nodules (n = 56, 14.89%), sinus disease (n = 39, 10.37%), intracranial or cervical artery aneurysms (n = 30, 7.98%), enlarged lymph nodes (n = 24, 6.38%), and pulmonary embolism (n = 19, 5.05%). In addition, 184 (48.94%) of them were not mentioned in the initial report. The highest incidence of missed potential clinical findings were pulmonary embolism and pathologic fractures and erosions (100% for both). The unreported rate of the chest group was significantly higher than that of the head or neck one, regardless of Type I, Type II or all potential clinically significant IFs (χ = 32.151, χ = 31.211, χ = 65.286, respectively; P < .001 for all).Important clinically significant incidental findings are commonly found in a proportion of patients undergoing neck CTA, in which nearly half of these patients have had potential clinically significant IFs not diagnosed in the initial report. Therefore, radiologists should beware of the importance of and the necessity to identify incidental findings in neck CTA scans.


Assuntos
Angiografia por Tomografia Computadorizada , Achados Incidentais , Diagnóstico Ausente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Aneurisma Intracraniano/diagnóstico por imagem , Doenças Linfáticas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Nódulos Pulmonares Múltiplos/diagnóstico por imagem , Doenças dos Seios Paranasais/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Nódulo Pulmonar Solitário/diagnóstico por imagem , Nódulo da Glândula Tireoide/diagnóstico por imagem
13.
Diabetes Res Clin Pract ; 167: 108353, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32739381

RESUMO

AIMS: We assessed how altered diagnostic processes and criteria for gestational diabetes mellitus (GDM) recommended by the United Kingdom (UK), Canada and Australia for use during the COVID-19 pandemic would affect both GDM frequency and related adverse outcomes. METHODS: Secondary analysis of 5974 HAPO study women with singleton pregnancies who underwent 75 g OGTTs and HbA1c assays between 24 and 32 weeks' gestation and who received no treatment for GDM. RESULTS: All post COVID-19 modified pathways reduced GDM frequency - UK (81%), Canada (82%) and Australia (25%). Canadian women whose GDM would remain undetected post COVID-19 (missed GDMs) displayed similar rates of pregnancy complications to those with post COVID-19 GDM. Using UK modifications, the missed GDM group were at slightly lower risk whilst the women missed using the Australian modifications were at substantially lower risk. CONCLUSIONS: The modifications in GDM diagnosis proposed for the UK, Canada and Australia result in differing reductions of GDM frequency. Each has both potential benefits in terms of reduction in potential exposure to COVID-19 and costs in terms of missed opportunities to influence pregnancy and postpartum outcomes. These factors should be considered when deciding which protocol is most appropriate for a particular context.


Assuntos
Glicemia/metabolismo , Infecções por Coronavirus/prevenção & controle , Diabetes Gestacional/diagnóstico , Teste de Tolerância a Glucose/métodos , Diagnóstico Ausente/estatística & dados numéricos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Complicações Infecciosas na Gravidez/prevenção & controle , Adulto , Austrália , Betacoronavirus , Canadá , Diabetes Gestacional/metabolismo , Jejum , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Guias de Prática Clínica como Assunto , Gravidez , Resultado da Gravidez , Segundo Trimestre da Gravidez , Terceiro Trimestre da Gravidez , Reino Unido
14.
PLoS One ; 15(8): e0237993, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32822388

RESUMO

INTRODUCTION: Complete follow-up of human immunodeficiency virus (HIV)-exposed infants (HEI) is crucial for a successful prevention of mother-to-child HIV transmission. This study analyzed the HEI follow-up and factors associated with loss to follow-up (LTFU) in southern Mozambique. METHODS: This retrospective cohort study used the data of HEI enrolled between June 2017 and June 2018, followed-up for 18 months. The outcomes were the proportion of infants with completed follow-up and a definitive diagnosis, and the presence of clinical events. Kaplan-Meier survival analysis was used to calculate the cumulative probability of LTFU and of clinical events. Factors associated with LTFU and clinical events were analyzed using Cox regression to calculate the hazard ratio (HR) and adjusted HR (AHR), with a 95% confidence interval (CI) and a significance cutoff of p<0.05. RESULTS: 1413 infants were enrolled (49% males) at a median age of 32 days (IQR 31-41); the median follow-up time was 12 months (IQR 8.2-14.2); 1129 (80%) completed follow-up and had a definitive diagnosis, 58 (4%) were HIV-positive, 225 (16%) were LTFU; 266 (19%) presented a clinical event. Factors associated with LTFU were: age >2 months at entry (AHR, 1.58; 95% CI, 1.12-2.23), non-exclusive breastfeeding (AHR, 1.44; 95% CI, 1.01-2.06), poor cotrimoxazole adherence (AHR, 3.42; 95% CI, 1.59-7.35), and clinical events (AHR, 0.51; 95% CI, 0.34-0.77). Factors associated with clinical events were: malnutrition (AHR, 10.06; 95% CI, 5.92-17.09), non-exclusive breastfeeding (AHR, 1.98; 95% CI, 1.34-2.93), no nevirapine prophylaxis (AHR, 1.67; 95% CI, 1.18-2.36), and poor cotrimoxazole adherence (AHR, 2.62; 95% CI, 1.10-6.22). CONCLUSION: The high rate of HEI LTFU, associated with delayed linkage to postnatal care, poor prophylaxis adherence, non-exclusive breastfeeding, indicates the need to design a differentiated service delivery model that is tailored to the mothers' and infants' specific needs.


Assuntos
Infecções por HIV/diagnóstico , Transmissão Vertical de Doença Infecciosa/estatística & dados numéricos , Antirretrovirais/uso terapêutico , Aleitamento Materno , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Lactente , Perda de Seguimento , Masculino , Adesão à Medicação , Diagnóstico Ausente/estatística & dados numéricos , Moçambique , Nevirapina/uso terapêutico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico
15.
Eur J Vasc Endovasc Surg ; 60(5): 703-710, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32718828

RESUMO

OBJECTIVE: Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. METHODS: This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). RESULTS: In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006). CONCLUSION: Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.


Assuntos
Amputação/estatística & dados numéricos , Isquemia/diagnóstico , Diagnóstico Ausente/estatística & dados numéricos , Doença Arterial Periférica/diagnóstico , Atenção Primária à Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Diagnóstico Precoce , Grupos Étnicos/estatística & dados numéricos , Feminino , Humanos , Isquemia/prevenção & controle , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Diagnóstico Ausente/prevenção & controle , Doença Arterial Periférica/tratamento farmacológico , Doença Arterial Periférica/cirurgia , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Reino Unido
17.
Zhonghua Wai Ke Za Zhi ; 58(7): 490-493, 2020 Jul 01.
Artigo em Chinês | MEDLINE | ID: mdl-32610416

RESUMO

Incidental gallbladder cancer(IGBC) originated in the West more than half a century ago.IGBC was translated and introduced into China afterwards with widespread clinical application.With the popularization of laparoscopic cholecystectomy, the trend of "abuse" of IGBC has become increasingly apparent worldwide.Many advanced gallbladder cancers have been categorized as IGBC which actually become the synonym of "missed diagnosis" . From the point of the pathology, the diagnosis of IGBC may cause delays in treatment and adversely affect the patient's prognosis.For country like China with relatively high incidences of chronic cholecystitis, cholelithiasis, and gallbladder cancer, the concept of IGBC, however, is no longer applicable to our diagnosis treat model.For improving the prognosis of gallbladder patients, it is necessary to update and rename the concept of IGBC and more attention should be paid to improve the diagnostic level of early stage tumor.


Assuntos
Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/cirurgia , Diagnóstico Ausente , Terminologia como Assunto , China , Colecistectomia Laparoscópica , Colecistite/cirurgia , Colelitíase/cirurgia , Neoplasias da Vesícula Biliar/patologia , Humanos , Achados Incidentais , Estadiamento de Neoplasias , Prognóstico , Tempo para o Tratamento
18.
Am J Gastroenterol ; 115(10): 1689-1697, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32558682

RESUMO

INTRODUCTION: Numerous guidelines exist for the management of pancreatic cysts. We sought to compare the guideline-directed management strategies for pancreatic cysts by comparing 2 approaches (2017 International Consensus Guidelines and 2015 American Gastroenterological Association Guidelines) that differ significantly in their thresholds for imaging, surveillance, and surgery. METHODS: We developed a Monte Carlo model to evaluate the outcomes for a cohort of 10,000 patients managed per each guideline. The primary outcome was mortality related to pancreatic cyst management. Secondary outcomes included all-cause mortality, missed cancers, number of surgeries, number of imaging studies, cumulative cost, and quality-adjusted life years. RESULTS: Deaths because of pancreatic cyst management and quality-adjusted life years were similar in both guidelines at a significantly higher cost of $3.6 million per additional cancer detected in the Consensus Guidelines. Deaths from "unrelated" causes (1,422) vastly outnumbered deaths related to pancreatic cysts (125). Secondary outcomes included more missed cancers in the American Gastroenterological Association guideline (71 vs 49), more surgeries and imaging studies in the Consensus guideline (711 vs 163; 116,997 vs 68,912), and higher cost in the Consensus guideline ($168.3 million vs $89.4 million). As the rate of malignant transformation increases, a more-intensive guideline resulted in fewer deaths related to pancreatic cyst management. DISCUSSION: Our study demonstrates trade-offs between more- and less-intensive management strategies for pancreatic cysts. Although deaths related to pancreatic cyst management were similar in each strategy, fewer missed cancers in the more-intensive surveillance strategy is offset by a greater number of surgical deaths and higher cost. In conclusion, our study identifies that if the rate malignant transformation of pancreatic cysts is low (0.12% annually), a less-intensive guideline will result in similar deaths to a more-intensive guideline at a much lower cost.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Diagnóstico Ausente/estatística & dados numéricos , Cisto Pancreático/diagnóstico , Cisto Pancreático/cirurgia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Guias de Prática Clínica como Assunto , Idoso , Simulação por Computador , Detecção Precoce de Câncer , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/economia , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/métodos , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Mortalidade , Cisto Pancreático/economia , Neoplasias Pancreáticas/economia , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento
19.
Surgery ; 168(2): 305-312, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32471653

RESUMO

BACKGROUND: Owing to substantial costs and increasing interest in the nonoperative management of appendicitis, the necessity of routine histopathologic examination of appendectomy specimens is being questioned. The aim of this study was to determine whether routine histopathologic examination after appendectomy for suspected appendicitis should still be performed. METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies listing the histopathologic diagnoses after appendectomy for suspected appendicitis. Main outcomes were the incidence of histopathologically proven aberrant findings, the ability of surgeons to recognize unexpected appendiceal pathology intraoperatively, and the percentage of aberrant findings resulting in a change of postoperative management. A meta-analysis was performed using a random-effects model. RESULTS: Twenty-five studies with 57,357 patients were included. The pooled percentage of aberrant findings was 2.52% (95% confidence interval 1.81-3.51). Neoplasms were found in 0.71% (95% confidence interval 0.54-0.94). Findings of the intraoperative assessment by the surgeon were reported for 82 of the 2,718 (3.0%) unexpected diagnoses, with great variation between studies. The impact on postoperative management was described for 237 of 2,718 (8.7%) aberrant findings. Of these, 166 (70.0%) resulted in a change of postoperative management. CONCLUSION: Based on current evidence, it remains unclear how many of the unexpected appendiceal pathologies with clinical consequences can be identified intraoperatively by the surgeon. Until reliable data on the safety and potential cost savings of a selective policy becomes available, we advise sending appendectomy specimens routinely for histopathologic examination.


Assuntos
Apendicectomia , Apendicite/cirurgia , Apêndice/patologia , Erros de Diagnóstico , Diagnóstico Ausente , Neoplasias do Apêndice/diagnóstico , Apendicite/diagnóstico , Endometriose/diagnóstico , Feminino , Granuloma/diagnóstico , Humanos , Período Intraoperatório , Doenças Parasitárias/diagnóstico , Cuidados Pós-Operatórios
20.
Ulus Travma Acil Cerrahi Derg ; 26(3): 431-438, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32436971

RESUMO

BACKGROUND: This study aimed to investigate the role of computed tomography (CT) in identifying missed unstable blunt cervical injuries. METHODS: Patients admitted to the emergency department between June 2014 and June 2018 with a diagnosis of blunt cervical trauma were included in this study. All participants underwent cervical magnetic resonance imaging (MRI) after an initial cervical CT investigation. All imaging results were reviewed, and decisions were taken by the consensus of a team consisting of an emergency medicine specialist, a neuroradiologist, and a neurosurgeon. Other variables included age, sex, the Glasgow Coma Scale, medical comorbidities, multi-trauma, neurological deficits, accompanying intracranial hemorrhage, extremity fractures, and the mechanism of the injury. RESULTS: Data for 195 patients were analyzed. The mean (±standard deviation) age of the participants was 47.34±21.90 years, and 140 (71.8%) were males. Eighteen patients (9.2%) were below age <18. The most frequent mechanism of injury was fall from height (n=100; 51.3%). Using MRI as the gold standard, the sensitivity of CT in diagnosing unstable cervical injury was 77.7% (95% CI [67.1-86.1]), while its specificity was 100.0% (95% CI [59.0-100.0]). CONCLUSION: Although computed tomography is relatively good in diagnosing unstable cervical injuries, its sensitivity in detecting positive cases is not as successful. Thus, the use of MRI in patients with an unstable injury seems to be warranted.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Imagem por Ressonância Magnética , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diagnóstico Ausente
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