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1.
BMC Surg ; 21(1): 159, 2021 Mar 22.
Artigo em Inglês | MEDLINE | ID: mdl-33752671

RESUMO

BACKGROUND: Sentinel lymph node biopsy (SLNB) is unnecessarily performed too often, owing to the high upstaging rates of ductal carcinoma in situ (DCIS). This study aimed to evaluate the upstaging rates of DCIS to invasive cancer, determine the prevalence of axillary lymph node metastasis, and identify the clinicopathological factors associated with upstaging and lymph node metastasis. We also examined surgical patterns among DCIS patients and determined whether SLNB guidelines were followed. METHODS: We retrospectively analysed 307 consecutive DCIS patients diagnosed by preoperative biopsy in a single centre between 2014 and 2018. Data from clinical records, including imaging studies, axillary and breast surgery types, and pathology results from preoperative and postoperative biopsies, were extracted. Univariate analyses using Chi-square tests and multiple logistic regression analyses were used to analyse the data. RESULTS: The rate of upstaging to invasive cancer was 19.2% (59/307). DCIS diagnosed by core-needle biopsy (odds ratio [OR]: 6.861, 95% confidence interval [CI]: 2.429-19.379), the presence of ultrasonic mass-forming lesions (OR: 2.782, 95% CI: 1.224-6.320), and progesterone receptor-negative status (OR: 3.156, 95% CI: 1.197-8.323) were found to be associated with upstaging. The rate of sentinel lymph node metastasis was only 1.9% (4/202), and all were total mastectomy patients diagnosed by core-needle biopsy. SLNB was performed in 37.2% of 145 breast-conserving surgery patients and 91.4% of 162 total mastectomy patients. Among the 202 patients who underwent SLNB, 145 (71.7%) without invasive cancer on final pathology had redundant SLNB. Two of 59 patients (3.4%) with disease upstaged to invasive cancer had inadequate primary staging of the axilla, as the rate seemed sufficiently small. CONCLUSIONS: In patients with a preoperative diagnosis of DCIS, although an unavoidable possibility of upstaging to invasive cancer exists, axillary metastasis is unlikely. Only 2.7% of patients with DCIS undergoing total mastectomy were found to have sentinel lymph node metastases. SLNB should not be performed in breast-conserving surgery patients and should be reserved only for total mastectomy patients diagnosed by core-needle biopsy.


Assuntos
Neoplasias da Mama , Carcinoma Intraductal não Infiltrante , Biópsia de Linfonodo Sentinela , Adulto , Axila/patologia , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Feminino , Humanos , Mastectomia , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Desnecessários
2.
JAMA ; 325(10): 971-987, 2021 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-33687468

RESUMO

Importance: Lung cancer is the leading cause of cancer-related death in the US. Objective: To review the evidence on screening for lung cancer with low-dose computed tomography (LDCT) to inform the US Preventive Services Task Force (USPSTF). Data Sources: MEDLINE, Cochrane Library, and trial registries through May 2019; references; experts; and literature surveillance through November 20, 2020. Study Selection: English-language studies of screening with LDCT, accuracy of LDCT, risk prediction models, or treatment for early-stage lung cancer. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled because of heterogeneity of populations and screening protocols. Main Outcomes and Measures: Lung cancer incidence, lung cancer mortality, all-cause mortality, test accuracy, and harms. Results: This review included 223 publications. Seven randomized clinical trials (RCTs) (N = 86 486) evaluated lung cancer screening with LDCT; the National Lung Screening Trial (NLST, N = 53 454) and Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON, N = 15 792) were the largest RCTs. Participants were more likely to benefit than the US screening-eligible population (eg, based on life expectancy). The NLST found a reduction in lung cancer mortality (incidence rate ratio [IRR], 0.85 [95% CI, 0.75-0.96]; number needed to screen [NNS] to prevent 1 lung cancer death, 323 over 6.5 years of follow-up) with 3 rounds of annual LDCT screening compared with chest radiograph for high-risk current and former smokers aged 55 to 74 years. NELSON found a reduction in lung cancer mortality (IRR, 0.75 [95% CI, 0.61-0.90]; NNS to prevent 1 lung cancer death of 130 over 10 years of follow-up) with 4 rounds of LDCT screening with increasing intervals compared with no screening for high-risk current and former smokers aged 50 to 74 years. Harms of screening included radiation-induced cancer, false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, and increases in distress. For every 1000 persons screened in the NLST, false-positive results led to 17 invasive procedures (number needed to harm, 59) and fewer than 1 person having a major complication. Overdiagnosis estimates varied greatly (0%-67% chance that a lung cancer was overdiagnosed). Incidental findings were common, and estimates varied widely (4.4%-40.7% of persons screened). Conclusions and Relevance: Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.


Assuntos
Detecção Precoce de Câncer , Neoplasias Pulmonares/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Detecção Precoce de Câncer/efeitos adversos , Reações Falso-Positivas , Humanos , Pulmão/diagnóstico por imagem , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Sobremedicalização , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Fatores de Risco , Sensibilidade e Especificidade , Fumar/efeitos adversos , Procedimentos Desnecessários
3.
Orv Hetil ; 162(14): 530-541, 2021 03 30.
Artigo em Húngaro | MEDLINE | ID: mdl-33784246

RESUMO

Összefoglaló. A pajzsmirigy az elso szervek közé tartozik, melyek megjelenítésében, betegségeinek felfedezésében az ultrahang-diagnosztikának fontos szerepe van. A pajzsmirigybetegségek a lakosság jelentos részét érintik, és a technika fejlodésével egyre több pajzsmirigyeltérés, göb kerül felfedezésre. A pajzsmirigy rosszindulatú folyamatainak nincs egy bizonyos specifikus jele, viszont az ultrahangkép alapján meghatározhatók a malignitásra gyanús eltérések. Erre az elmúlt években több összefoglaló rendszer is született. Jelen összefoglaló tanulmányunknak az a célja, hogy bemutassuk a pajzsmirigy ultrahangdiagnosztikájának fejlodését; összehasonlítsuk az egyes leletezési rendszereket, úgymint TIRADS, EU-TIRADS, K-TIRADS, melyek célja a feltehetoleg rosszindulatú göbök kiszurése, azonosítása a mindennapi rutinmunka során; vizsgáljuk a különbözo rendszerek kapcsolatát a patológia által használt Bethesda-pontrendszerrel. Az ultrahangvizsgálat megfelelo értékelése, a pontrendszerek ismerete segíthet a pajzsmirigygöb differenciáldiagnózisában, a követési frekvencia meghatározásában, csökkentheti az aspirációs citológiák számát, ezzel támogatva a klinikai döntéshozatalt. Orv Hetil. 2021; 162(14): 530-541. Summary. The thyroid gland was one of the first organs, the ultrasound (US) examination of which has played an important role. The thyroid diseases affect a large part of the population, and with the development of imaging technology, more and more thyroid abnormalities, nodules and malignant lesions are being discovered. There are no specific signs of thyroid cancer, but the suspicious signs could be determined by US. In recent years, several systems have been developed. The aim of our review is to demonstrate the development of US diagnostics of the thyroid gland; to compare the different reporting systems, such as TIRADS, EU-TIRADS, K-TIRADS, which should help to identify the questionable lesions in the daily routine work. We examine the relationship between the different US systems and the Bethesda point score used by pathologists. The literature review shows that the US examination supports the clinical decisions, helps to select, who should have a fine-needle biopsy, and allows to determine the frequency of follow-up. The number of unnecessary fine-needle biopsies could be reduced, too. Our paper is part of a bigger research, the ethical license number is 23/2020, University of Szeged. Orv Hetil. 2021; 162(14): 530-541.


Assuntos
Doenças da Glândula Tireoide , Glândula Tireoide , Biópsia por Agulha Fina , Humanos , Doenças da Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/diagnóstico por imagem , Ultrassonografia , Procedimentos Desnecessários
5.
J Orthop Sports Phys Ther ; 51(2): 53-56, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33522383

RESUMO

SUMMARY: Shared decision making is recommended as a strategy to help patients identify what matters most to them and make informed decisions about musculoskeletal care. In part 5 of the Overcoming Overuse series, we look at the evidence supporting shared decision making as a strategy to help curb overuse. Using shared decision making in clinical consultations may help to reduce the overuse of options that are not beneficial and to increase use of care supported by evidence. Shared decision making could support clinicians in promoting uptake of active rehabilitation options with a favorable balance of benefits to harms. Shared decision making facilitates conversations about unnecessary tests or treatments and could be a key strategy for overcoming overuse. J Orthop Sports Phys Ther 2021;51(2):53-56. doi:10.2519/jospt.2021.0103.


Assuntos
Tomada de Decisão Compartilhada , Dor Musculoesquelética/terapia , Participação do Paciente , Modalidades de Fisioterapia , Procedimentos Desnecessários , Humanos
6.
J Med Case Rep ; 15(1): 97, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33632292

RESUMO

BACKGROUND: Lichen planus is a rare autoimmune disease primarily affecting the skin and mucous membranes of the oral mucosa, vulva, and vagina. Diagnosis is difficult and often delayed as the clinicians do not associate the oral symptoms with the genital symptoms. This has a negative impact on the out-of-pocket expenditure and quality of life of the patients. We report this case, as only anecdotal cases have been reported so far from a developing country such as India. We highlight the unindicated hysterectomy that the patient had undergone because of lack of awareness regarding this condition. Our case report also highlights the importance of the multidisciplinary team approach to optimize outcomes and avoid unnecessary morbidity to such patients. CASE PRESENTATION: We report a North-Indian patient with oro-vaginal-vulvar lichen planus who presented to us with complaints of recurrent vulvovaginal symptoms for the last 5 years. She had been previously treated with multiple courses of antibiotics, antifungals, and topical steroids over the course of 3 years and finally offered laparoscopic-assisted vaginal hysterectomy (LAVH) by a private practitioner but got no relief. She also had complained of oral symptoms in the form of a burning sensation after eating spicy food, but did not seek any treatment for this. After multidisciplinary team discussion, a final diagnosis of oro-vaginal-vulvar lichen planus was made at our institute based on the clinical and histopathological findings. The patient was immediately started on oral prednisolone to which she responded with improvement in her symptoms. CONCLUSION: Lichen planus is a chronic painful condition with significant impact on the quality of life. Women often suffer for several years before an accurate diagnosis is made. Treatment is challenging and needs to be individualized with a multidisciplinary approach to prevent progressive anatomical distortion and associated morbidity.


Assuntos
Histerectomia Vaginal , Líquen Plano/diagnóstico , Líquen Plano/tratamento farmacológico , Líquen Plano/cirurgia , Prednisolona/uso terapêutico , Procedimentos Desnecessários , Adulto , Feminino , Humanos , Índia/epidemiologia , Mucosa Bucal/patologia , Qualidade de Vida , Resultado do Tratamento , Doenças Vaginais/diagnóstico , Doenças da Vulva/diagnóstico
7.
Int J Med Sci ; 18(2): 520-527, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33390821

RESUMO

Background: Multiple societies including the Fleischner Society do not recommend that CT is routinely used in asymptomatic SARS-CoV-2 infections; however, this advice is based on the limited evidence. In this study, we aim to confirm whether it is necessary to do CT scans in SARS-CoV-2 asymptomatic infections by summarizing the longitudinal chest CT and clinical features of asymptomatic SARS-CoV-2 infections. Methods: A total of 33 individuals (14 men and 19 women) with asymptomatic SARS-CoV-2 infections were retrospectively enrolled. Clinical data of CT positive and negative groups were compared. Longitudinal chest CT scans were reviewed for CT features and analyzed for temporal change. Results: Thirty-two (97%) individuals had positive results for first RT-PCR testing. For clinical data, only monocyte count showed a significant difference between CT positive and negative groups. For first chest CT, only eighteen (54.5%) individuals had abnormal manifestations, common CT features were GGO (88.9%) and consolidation (33.3%), the median number of segments involved was 3.0 (1.0-7.5). No case in CT negative group was abnormal on the follow-up CT. Three patterns of evolution throughout series of CT were observed in CT positive group, including gradual improvement (12, 66.7%), mismatch to improvement (3, 16.7%) and mild progression to improvement (3, 16.7%). On last CT scans, most cases had radiographic improvement but residual abnormalities. Significant differences were exhibited in density, long diameter, number of lung segments involved, and percentage of consolidation between the first and last CT scans. All cases had stable conditions and finally confirmed negative for SARS-CoV-2 RT-PCR tests without developing into severe pneumonia. Conclusion: Considering poor performance of CT in screening, stable conditions during followup, and good outcomes in asymptomatic SARS-CoV-2 infections, we confirm that it is unnecessary to do CT scans in asymptomatic SARS-CoV-2 infections.


Assuntos
Infecções Assintomáticas , Radiografia Torácica , Tomografia Computadorizada por Raios X , Adulto , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Desnecessários
8.
J Orthop Sports Phys Ther ; 51(1): 1-4, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33383998

RESUMO

SUMMARY: The challenge of overuse raises important questions for those in the business of musculoskeletal health care. What is the right number of physical therapy visits for a given condition? Can a practice provide "less" but still be profitable? In this, the editorial on overcoming overuse of musculoskeletal health care, we consider the economic drivers of overuse in the private sector. We propose actions that could support small business leaders to overcome overuse and build profitable, high-quality services. J Orthop Sports Phys Ther 2021;51(1):1-4. doi:10.2519/jospt.2021.0101.


Assuntos
Doenças Musculoesqueléticas/economia , Doenças Musculoesqueléticas/terapia , Modalidades de Fisioterapia/economia , Gerenciamento da Prática Profissional/economia , Empresa de Pequeno Porte/economia , Procedimentos Desnecessários/economia , Humanos
9.
Braz J Med Biol Res ; 54(2): e10466, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33439935

RESUMO

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.


Assuntos
Anestesia , Doença da Artéria Coronariana , Procedimentos Desnecessários , Adulto , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Feminino , Cardiopatias , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
10.
J Surg Res ; 257: 529-536, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32919343

RESUMO

BACKGROUND: Previous investigation has shown that the combined predictive value of white blood cell count and ultrasound (US) findings to be superior to either alone in children with suspected appendicitis. The purpose of this study was to evaluate the impact of a diagnostic clinical pathway (DCP) leveraging the combined predictive value of these tests on computed tomography (CT) utilization and resource utilization. METHODS: Retrospective cohort study comparing 8 mo of data before DCP implementation to 18 mo of data following implementation. The pathway incorporated decision-support for disposition (operative intervention, observation, or further cross-sectional imaging) based on the combined predictive value of laboratory and US data (stratifying patients into low, moderate, and high-risk groups). Study measures included CT and magnetic resonance imaging utilization, imaging-related cost, time to appendectomy, and negative appendectomy rate. RESULTS: Ninety-seven patients in the preintervention period were compared with 319 patients in the postintervention period. Following DCP implementation, CT utilization decreased by 86% (21% versus 3%, P < 0.001). Mean time to appendectomy decreased from 8.5 to 7.2 h (P < 0.001), and the negative appendectomy rate remained unchanged (5% versus 4%, P = 0.54). Magnetic resonance imaging utilization increased following pathway implementation (1% versus 7%, P = 0.02); however, median imaging-related cost was significantly lower in the postimplementation period ($283/case to $270/case, P = 0.002) CONCLUSIONS: In children with suspected appendicitis, implementation of a DCP leveraging the combined predictive value of white blood cell and US data was associated with a reduction in CT utilization, time to appendectomy, and imaging-related cost.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/diagnóstico por imagem , Procedimentos Clínicos/estatística & dados numéricos , Exposição à Radiação/prevenção & controle , Ultrassonografia , Adolescente , Apendicite/sangue , Apendicite/cirurgia , Criança , Feminino , Humanos , Contagem de Leucócitos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Tempo para o Tratamento , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
11.
J Surg Res ; 257: 394-398, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892136

RESUMO

INTRODUCTION: Patients presenting to the Emergency Department (ED) following head injury are frequently evaluated with an initial computed tomography scan (CT) of the brain. Imaging is particularly important in patients who are receiving medications that alter normal blood hemostasis. As an imaging modality, CT has a high negative predictive value when used to rule out clinically significant acute intracranial hemorrhage. Patients receiving anticoagulant or antiplatelet therapy have both an increased risk of initial hemorrhage, as well as an increased risk of mortality above nonanticoagulated patients, should they suffer hemorrhage. Multiple studies of delayed intracranial hemorrhage have placed the risk among the patients taking warfarin at the time of head injury in the range of 0.6-6.0%. However, data regarding the risk of delayed intracranial hemorrhage in patients taking the class of agents referred to as Direct-Acting Oral Anticoagulants (DOACs) remains limited. This study aims to estimate this risk. METHODS: A retrospective chart review was performed to identify patients on DOACs who presented to our Level I trauma center following blunt head injury between January 2017 and August 2018. Patients with a negative initial head CT were selected. From this subset, data regarding demographics, injury characteristics, anticoagulant use, and antiplatelet use were collected. RESULTS: Overall, 314 patients were included; 129 patients taking rivaroxaban, 182 patients taking apixaban, and four patients taking dabigatran. In approximately 29% of the patients, the sole indication for admission was close monitoring following head injury while taking an anticoagulant agent. The mechanism of injury for the majority of the patients was fall. Of the 314 patients, three were found to have delayed intracranial hemorrhage on the repeated head CT (0.95%). Two of these three patients were on concomitant antiplatelet medication. None of the three individuals required neurosurgical intervention. CONCLUSIONS: at the time of submission, this is the largest study estimating the risk of delayed intracranial hemorrhage among patients on DOACs. Based on the results of this study, patients who sustain a blunt head injury while taking only DOACs; that is, without concurrent antiplatelet medication, admission, and repeat head CT may not be necessary after confirming a negative initial CT scan.


Assuntos
Anticoagulantes/efeitos adversos , Hemorragia Intracraniana Traumática/induzido quimicamente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Procedimentos Desnecessários , Adulto Jovem
12.
Am Fam Physician ; 103(1): 42-50, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33382559

RESUMO

The use of diagnostic radiography has doubled in the past two decades. Image Gently (children) and Image Wisely (adults) are multidisciplinary initiatives that seek to reduce radiation exposure by eliminating unnecessary procedures and offering best practices. Patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 may have increased risk of nephropathy when exposed to iodinated contrast media and increased risk of nephrogenic systemic fibrosis when exposed to gadolinium-based contrast agents. American College of Radiology Appropriateness Criteria can help guide specific diagnostic imaging choices. Noncontrast head computed tomography is the first-line modality when a stroke is suspected. Magnetic resonance imaging stroke protocols and computed tomography perfusion scans can augment evaluation and potentially expand pharmacologic and endovascular therapy timeframes. Imaging should be avoided in patients with uncomplicated headache syndromes unless the history or physical examination reveals red flag features. Cardiac computed tomography angiography, stress echocardiography, and myocardial perfusion scintigraphy (nuclear stress test) are appropriate for patients with chest pain and low to intermediate cardiovascular risk and have comparable sensitivity and specificity. Computed tomography pulmonary angiography is the preferred test for high-risk patients or those with a positive d-dimer test result, and ventilation-perfusion scintigraphy is reserved for patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 or a known contrast allergy. Computed tomography with intravenous contrast is preferred for evaluating adults with suspected appendicitis; however, ultrasonography should precede computed tomography in children, and definitive treatment should be initiated if positive. Ultrasonography is the first-line modality for assessing right upper quadrant pain suggestive of biliary disease. Mass size and patient age dictate surveillance recommendations for adnexal masses. Imaging should not be performed for acute (less than six weeks) low back pain unless red flag features are found on patient history. Ultrasonography should be used for the evaluation of suspicious thyroid nodules identified incidentally on computed tomography.


Assuntos
Imagem por Ressonância Magnética/normas , Neoplasias Induzidas por Radiação/prevenção & controle , Segurança do Paciente/normas , Radiografia/normas , Cintilografia/normas , Humanos , Guias de Prática Clínica como Assunto , Saúde Radiológica , Tomografia Computadorizada por Raios X/normas , Procedimentos Desnecessários/efeitos adversos
13.
Rev Paul Pediatr ; 40: e2020302, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33331510

RESUMO

OBJECTIVE: To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19. DATA SOURCES: Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded. DATA SYNTHESIS: 61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review. CONCLUSIONS: It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children's exposure to ionizing agents.


Assuntos
/diagnóstico por imagem , Pediatria/métodos , Criança , Serviço Hospitalar de Emergência/organização & administração , Humanos , Pulmão/diagnóstico por imagem , Pandemias , Tomografia Computadorizada por Raios X/efeitos adversos , Ultrassonografia/efeitos adversos , Procedimentos Desnecessários
14.
N Z Med J ; 133(1527): 71-82, 2020 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-33332329

RESUMO

AIM: To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy. METHODS: The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology. RESULTS: Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98.1% and a negative predictive value of 99.9% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway. CONCLUSIONS: The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.


Assuntos
Carcinoma de Células de Transição/diagnóstico por imagem , Carcinoma de Células de Transição/urina , Procedimentos Clínicos , Hematúria/etiologia , Neoplasias da Bexiga Urinária/diagnóstico por imagem , Neoplasias da Bexiga Urinária/urina , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/urina , Carcinoma de Células de Transição/complicações , Cistite/complicações , Cistite/diagnóstico , Cistoscopia , Feminino , Hematúria/diagnóstico por imagem , Humanos , Rim/diagnóstico por imagem , Cálculos Renais/complicações , Cálculos Renais/diagnóstico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Doenças Prostáticas/complicações , Doenças Prostáticas/diagnóstico , Encaminhamento e Consulta , Tomografia Computadorizada por Raios X , Ultrassonografia , Procedimentos Desnecessários , Neoplasias da Bexiga Urinária/complicações , Infecções Urinárias/complicações , Infecções Urinárias/diagnóstico , Adulto Jovem
15.
Medicine (Baltimore) ; 99(42): e22412, 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33080675

RESUMO

In many German trauma centres, it is routine to perform abdominal follow-up sonography (AFS) 6 h after admission for patients with multiple trauma, even if the clinical course is uneventful and multi-slice computed tomography (MSCT) reveals no abdominal pathology. However, this approach is not recommended in the German Guidelines for trauma, and recent studies have questioned the value of AFS to these patients. The present study aimed to evaluate the revised German Guidelines for trauma with respect to the omission of AFS.We included patients with multiple injuries with no clinical signs of abdominal trauma and with normal abdominal MSCT. We collected clinical data of 370 consecutive patients who underwent AFS (Group A) and another 370 consecutive patients who did not undergo AFS (Group B).No abdominal injury was missed by the omission of AFS, and thus, no patient suffered from its omission or benefitted from the use of AFS. In our study population, the negative predictive value of normal MSCT results combined with no clinical signs of abdominal trauma was 100% (95% confidence interval: 99.5%-100.0%).This single-centre study conducted in a large German trauma centre demonstrates AFS to have no utility in the diagnosis of abdominal injury. Moreover, omission of AFS for conscious patients without clinical signs of abdominal trauma and with negative abdominal MSCT does not appear to have negative consequences in terms of missed abdominal injury.Therefore, AFS can be safely omitted in the majority of cases of polytrauma, which simplifies the imaging workup tremendously.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Traumatismo Múltiplo/diagnóstico por imagem , Guias de Prática Clínica como Assunto , Ultrassonografia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Alemanha , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia , Índices de Gravidade do Trauma , Procedimentos Desnecessários
16.
Am Surg ; 86(8): 955-957, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32862671

RESUMO

BACKGROUND: Current treatment guidelines for ductal carcinoma in situ (DCIS) treated with mastectomy recommend sentinel lymph node biopsy (SLNB). In the modern era, there is a trend toward minimizing invasive staging and treatment of the axilla. In this study, we seek to determine the role of SLNB in patients undergoing mastectomy for the treatment of DCIS. METHODS: Patients undergoing mastectomy were identified from our institution's SLNB database from 2012 to 2016. Patients were included if core needle biopsy demonstrated DCIS. Patient demographics, tumor characteristics, and pathologic variables were abstracted. RESULTS: Of 187 patients undergoing mastectomy with SLNB from 2012 to 2016 for DCIS or invasive ductal carcinoma, 39 (21%) were diagnosed with DCIS on core biopsy. Mean age was 57 years. 70% were Caucasian, 18% were African American, 8% were Asian, and the remaining 5% were unknown. One patient (3%) had positive nodes on SLNB and underwent axillary lymph node dissection. Of those with DCIS on core biopsy, 14 (36%) were upstaged to invasive disease on final surgical pathology, including the patient with positive SLNB. Of the remaining 25 (64%) patients with DCIS on final pathology, 0 (0%) had SLNB positivity. CONCLUSION: Only 3% of patients with DCIS undergoing mastectomy were found to have SLN metastases. However, a significant number of patients (36%) were upstaged due to invasive cancer. Although limited by a small sample size, our results suggest that SLNB should still be recommended to patients undergoing mastectomy for DCIS on core needle biopsy due to the high rate of upstage rate to invasive disease.


Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mastectomia , Biópsia de Linfonodo Sentinela , Procedimentos Desnecessários , Adulto , Idoso , Axila , Biópsia com Agulha de Grande Calibre , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Feminino , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Estudos Retrospectivos
17.
Am J Emerg Med ; 38(9): 1867-1874, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32739858

RESUMO

BACKGROUND: Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. METHODS: Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. RESULTS: Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. CONCLUSIONS: Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.


Assuntos
Atitude do Pessoal de Saúde , Fidelidade a Diretrizes , Síncope/diagnóstico , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Grupos Focais , Fidelidade a Diretrizes/organização & administração , Humanos , Ciência da Implementação , Entrevistas como Assunto , Inovação Organizacional , Guias de Prática Clínica como Assunto , Inquéritos e Questionários , Síncope/terapia , Procedimentos Desnecessários
18.
J Stroke Cerebrovasc Dis ; 29(9): 105022, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807437

RESUMO

BACKGROUND: Isolated mental status changes as a presenting sign (EoSC+), are not uncommon stroke code triggers. As stroke alerts, they still require the same intensive resources be applied. We previously showed that EoSC+ strokes (EoSC+ Stroke+) account for 0.1-0.2% of all codes. Whether these result in thrombolytic treatment (rt-PA), and the characteristics/ risk factor profiles of EoSC+ Stroke+ patients, have not been reported. METHODS: Retrospective analysis of stroke codes from an IRB approved registry, from 2004 to 2018, was performed. EoSC+ was defined as a NIHSS>0 for Q1a, 1b, or 1c with remaining elements scored 0. Characteristics and risk factors were compared for EoSC+, EoSC-, EoSC+ Stroke+, and rt-PA (EoSC+ Stroke+TPA+) patients. RESULTS: EoSC+ occurred in 55/2982 (1.84%) of all stroke codes. EoSC+ Stroke+ occurred in 8/55 (14.5%) of EoSC+ codes and 8/2982 (0.27%) of all stroke codes. 6/8 (75%) of EoSC+ Stroke+ scored NIHSS=1. When comparing EoSC++versus EoSC-, Hispanic ethnicity (p=0.009), hypertension (p=0.02), and history of stroke/TIA (p=0.002) were less common in EoSC+. No demographic/risk factor differences were noted for EoSC+ Stroke+ vs. EoSC+ Stroke-. No cases of rt-PA eligibility/treatment were noted. In EoSC+ Stroke+ analysis, imaging positive stroke/intracranial hemorrhage was noted on only 3 cases (3/2982=0.10% of all stroke codes) and none were posterior stroke. CONCLUSIONS: EoSC+ rarely results in stroke/TIA (0.27%) or stroke (0.10%), and in our analysis never (0%) resulted in rt-PA. Sub-analysis did not show missed rt-PA or posterior strokes. Understanding characteristics, and knowing that EoSC+ Stroke+ patients are unlikely to receive rt-PA, may help triage stroke resources.


Assuntos
Encefalopatias/diagnóstico , Tomada de Decisão Clínica , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Encefalopatias/etiologia , Encefalopatias/psicologia , Bases de Dados Factuais , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Saúde Mental , Seleção de Pacientes , Valor Preditivo dos Testes , Proteínas Recombinantes/administração & dosagem , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/psicologia , Triagem , Procedimentos Desnecessários
19.
Am Surg ; 86(8): 1022-1025, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32809851

RESUMO

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t-test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica , Cálculos Biliares/diagnóstico por imagem , Icterícia Obstrutiva/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Procedimentos Desnecessários/estatística & dados numéricos , Colangiografia/métodos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Icterícia Obstrutiva/etiologia , Icterícia Obstrutiva/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade
20.
J Trauma Acute Care Surg ; 89(2): 365-370, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744833

RESUMO

BACKGROUND: Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center. METHODS: All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends. RESULTS: There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit. CONCLUSION: MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources. LEVEL OF EVIDENCE: Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.


Assuntos
Vértebras Cervicais/lesões , Serviço Hospitalar de Emergência , Imagem por Ressonância Magnética/estatística & dados numéricos , Traumatismos da Medula Espinal/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico por imagem , Adulto , Vértebras Cervicais/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Estados Unidos , Procedimentos Desnecessários
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