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1.
J Urol ; 203(2): 292-298, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31479397

RESUMO

PURPOSE: We sought to develop a triage strategy to reduce negative and indeterminate multiparametric magnetic resonance imaging scans in patients at risk for prostate cancer. MATERIALS AND METHODS: In this retrospective study we evaluated 865 patients with no prior prostate cancer diagnosis who underwent prostate multiparametric magnetic resonance imaging between 2009 and 2017. Age, prostate volume, prostate specific antigen and prostate specific antigen density were assessed as predictors of positive multiparametric magnetic resonance imaging, defined as PI-RADS™ (Prostate Imaging Reporting and Data System) version 2/Likert score 4 or greater. The cohort was split into a training cohort of 605 patients and a validation cohort of 260. The optimal threshold to rule out positive multiparametric magnetic resonance imaging was chosen to achieve a negative predictive value greater than 90%. RESULTS: All clinical variables were significant predictors of positive multiparametric magnetic resonance imaging (p <0.05). Prostate specific antigen density outperformed other parameters in diagnostic accuracy and did not significantly differ compared to a multivariate model (AUC=0.74 vs 0.75). At prostate specific antigen density greater than 0.078 ng/ml2 sensitivity, specificity, positive and negative predictive values were 94%, 29%, 22% and 95%, respectively, resulting in 25% fewer scans (64 of 260). In the multivariate model sensitivity, specificity, positive and negative predictive values were 85%, 32%, 22% and 91%, respectively, resulting in 29% fewer scans (75 of 260). Biopsies in men who would not have undergone multiparametric magnetic resonance imaging according to our proposed strategies revealed 2 clinically significant prostate cancers using prostate specific antigen density and 1 using the multivariate model. CONCLUSIONS: In patients at risk for prostate cancer applying a multivariate prediction model or a prostate specific antigen density cutoff of 0.078 ng/ml2 resulted in 25% to 29% fewer multiparametric magnetic resonance imaging scans performed while missing only a minimal number of clinically significant prostate cancers. Further prospective validation is required.


Assuntos
Calicreínas/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Carga Tumoral
2.
N Z Med J ; 132(1488): 11-20, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851657

RESUMO

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.


Assuntos
Sobremedicalização/prevenção & controle , Procedimentos Desnecessários/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adulto , Educação em Saúde , Humanos , Sobremedicalização/economia , Sobremedicalização/estatística & dados numéricos , Nova Zelândia , Procedimentos Desnecessários/economia , Urinálise/economia , Urinálise/métodos , Infecções Urinárias/diagnóstico , Infecções Urinárias/microbiologia
3.
N Z Med J ; 132(1488): 21-27, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851658

RESUMO

BACKGROUND: Urinalysis performed by dipstick testing is an aid to diagnosing urinary tract infections (UTI), and a tool in selecting patients who require urine culture and antibiotic treatment. Previous studies have demonstrated that UTI, especially in the elderly, are over-diagnosed and over-treated. We sought to study the pattern and yield of urinalysis and urine culture at our service in a tertiary institution. METHODS: A convenience sampling method was utilised to prospectively collect clinical data, through a pre-designed pro forma, from patients admitted to the General Medicine service at Christchurch Hospital between March and June 2016. RESULTS: The study included 395 patients, with a median age of 76 (range 15-100 years). The presence of urinary tract symptoms was documented in 94 patients (24%) and a non-specific syndrome of elevated temperature, confusion or subjective feverishness in 69 (17%). In symptomatic patients, 121 (74%) had a dipstick performed and 104 (86%) urine samples cultured. In the remaining patients, 181 (78%) had a dipstick performed and 81 (35%) had a urine sample sent for culture. CONCLUSIONS: We found a large number of urine dipsticks is being ordered unnecessarily in asymptomatic patients. A more useful test is urine microscopy and culture that is done on symptomatic patients only following careful clinical evaluation. Performing 'routine' urinalysis in patients presenting a wide variety of symptoms may lead to unnecessary urine cultures and treatment of asymptomatic bacteriuria. Efforts to reduce unnecessary tests and antibiotic treatment are a vital component of diagnostic stewardship programmes.


Assuntos
Medicina Geral/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Prospectivos , Procedimentos Desnecessários/estatística & dados numéricos , Infecções Urinárias/diagnóstico , Infecções Urinárias/epidemiologia , Adulto Jovem
4.
Bone Joint J ; 101-B(10): 1307-1312, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31564143

RESUMO

AIMS: In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries. PATIENTS AND METHODS: Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up. RESULTS: In 100 patients (59 female, 41 male; mean age 57 years), 91 of the fractures (91%) remained stable. In five of nine patients (55%) with secondary displacement, surgery was recommended. Comminution, present in 23 patients (23%), was identified as a predictor of secondary displacement (p < 0.001). Patients' age, sex, fracture configuration, and bone quality were not associated with secondary displacement (p ≥ 0.438). Nonoperative treatment resulted in a mean absolute Constant score (CS) of 80 (49 to 98), relative CS of 101% (63% to 138%), median subjective shoulder value of 95% (interquartile range (IQR) 90% to 100%), and median EuroQol five-dimensional questionnaire score of 0.89 (IQR 0.80 to 1.00) with bone union in all cases at one-year follow-up. CONCLUSION: Radiological re-evaluation was only necessary in patients presenting with comminution and may be redundant for 77% of patients with one-part proximal humerus fractures. Nonoperative treatment of one-part proximal humerus fractures remains the mainstay of treatment with a low rate of secondary surgery, a high union rate, and good clinical results. Cite this article: Bone Joint J 2019;101-B:1307-1312.


Assuntos
Tratamento Conservador/métodos , Consolidação da Fratura/fisiologia , Radiografia/estatística & dados numéricos , Sistema de Registros , Fraturas do Ombro/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Fixação de Fratura/métodos , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Radiografia/métodos , Fraturas do Ombro/terapia , Estatísticas não Paramétricas , Fatores de Tempo
5.
Braz J Infect Dis ; 23(5): 331-335, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31562852

RESUMO

The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.


Assuntos
Doenças Transmissíveis/diagnóstico , Sociedades Médicas , Procedimentos Desnecessários/estatística & dados numéricos , Brasil , Saúde Global , Pesquisa sobre Serviços de Saúde , Humanos
6.
Int J Gynaecol Obstet ; 147(2): 187-194, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31420869

RESUMO

OBJECTIVE: To investigate the association of socioeconomic status (SES) components (education, occupation, and household wealth) with number (1 or ≥2) and timing (planned/emergency) of cesarean delivery (CD) in Colombia, rates of which are well above the levels recommended by the World Health Organization. METHODS: A cross-sectional study using the 2015 Demographic and Health Survey (DHS) of Colombia was carried out; 38 718 women answered the woman only module. Binomial and multinomial logistic regression analyses were conducted to generate estimates of the association between markers of SES and likelihood of CD, timing of CD, and number of CDs. RESULTS: The analysis included 9977 women. Although education and wealth were strongly associated with CD (P<0.001), the association between occupation and CD suggested that women in agriculture were the least likely to experience CD (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.44-1.03, P=0.061); and women in the "poorer" household wealth category were more likely to have emergency (OR 1.57, CI 1.29-1.90, P<0.001) and two or more (OR 1.64, CI 1.29-2.40, P<0.001) CDs. CONCLUSION: Markers of SES are associated with CD overuse in Colombia, as well as the number and timing of CD. More robust qualitative inquiry including additional questions to the DHS survey are needed to elucidate reasons driving the overutilization of CD in the country, particularly among vulnerable populations.


Assuntos
Cesárea/estatística & dados numéricos , Fatores Socioeconômicos , Adolescente , Adulto , Colômbia/epidemiologia , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Razão de Chances , Fenótipo , Gravidez , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
8.
BMC Health Serv Res ; 19(1): 446, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31269933

RESUMO

BACKGROUND: Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS: Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS: Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS: The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.


Assuntos
Técnicas de Imagem Cardíaca/estatística & dados numéricos , Dor Lombar/diagnóstico por imagem , Mamografia/estatística & dados numéricos , Procedimentos Desnecessários , Canadá/epidemiologia , Estudos Transversais , Humanos , Sobremedicalização , Estudos Retrospectivos , Procedimentos Desnecessários/estatística & dados numéricos
9.
Lakartidningen ; 1162019 May 15.
Artigo em Sueco | MEDLINE | ID: mdl-31192381

RESUMO

Systematic reviews and meta-analyses have shown that there is little justification for vitamin D supplements to prevent infections, cancer and cardiovascular disease. Despite the limited evidence of effectiveness, the total number of ordered serum 25-hydroxyvitamin D (25(OH)D) tests has increased considerably in recent years. There seems to be an overuse of this test that does not provide meaningful benefit for patients. A passive introduction of new tests leads generally to a slow initiation of value-based diagnostics, as well as overuse and underuse of diagnostic tests. In this study, in Region Östergötland, we applied a ¼Choosing wisely« model that reversed a rising trend of 25(OH)D tests and reduced the number of unnecessary tests. The findings point to the need for strategic plans for introducing new analyses and approaches to counteract misuse of laboratory diagnostics. We recommend ¼Choosing wisely« models for the introduction of new analyses to facilitate appropriate laboratory diagnostics and to counteract long-term overuse.


Assuntos
Análise Química do Sangue/normas , Atenção Primária à Saúde/normas , Utilização de Procedimentos e Técnicas/normas , Vitamina D/análogos & derivados , Análise Química do Sangue/estatística & dados numéricos , Humanos , Atenção Primária à Saúde/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Suécia , Procedimentos Desnecessários/normas , Procedimentos Desnecessários/estatística & dados numéricos , Vitamina D/sangue
10.
Pediatrics ; 144(1)2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31171587

RESUMO

BACKGROUND: Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS: We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS: In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS: Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.


Assuntos
Técnicas de Laboratório Clínico/estatística & dados numéricos , Eletrólitos/análise , Laboratórios Hospitalares/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Técnicas de Laboratório Clínico/economia , Feminino , Gastroenterite/diagnóstico , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Laboratórios Hospitalares/economia , Masculino , Utilização de Procedimentos e Técnicas , Melhoria de Qualidade , Estudos Retrospectivos , Procedimentos Desnecessários/economia
12.
Monaldi Arch Chest Dis ; 89(2)2019 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-31199102

RESUMO

The philosophy and the history of the International Choosing Wisely movement, launched in the U.S. in 2012, are described. It grew and spread beyond what it was anticipated at the beginning because there is a rising concern of the medical community regarding the appropriate use of procedures and treatments placed into the market before an adequate evaluation of risks and benefits. Not only healthcare providers, but also patients, citizens and politicians, are becoming aware of the consequences of inappropriate decisions and behaviors since inappropriateness has economic (waste of resources), clinical (risks), but also ethical implications. In Italy the movement was launched and still is coordinated by the Slow Medicine organization, that created the campaign Doing more does not mean doing better - Choosing Wisely Italy, which aimed to improve clinical appropriateness through the reduction of unnecessary tests and treatments and the dialogue between physicians and patients. Currently, 44 societies of physicians, nurses, pharmacists and physiotherapists identified 230 recommendations about tests, treatments and procedures commonly used in Italy's clinical practice that do not provide any benefit to most patients but may cause harm.


Assuntos
Relações Médico-Paciente , Procedimentos Desnecessários/estatística & dados numéricos , Humanos , Internacionalidade , Itália , Sociedades/estatística & dados numéricos
13.
Int J Pediatr Otorhinolaryngol ; 123: 22-25, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31054537

RESUMO

OBJECTIVES: The objective of this study is to examine the impact that an institution-wide policy to reduce radiation exposure in pediatric patients had on the use of computed tomography (CT) imaging in children presenting with suspected peritonsillar abscess (PTA)1. METHODS: A single institution retrospective review was conducted for all pediatric patients under the age of 18 who presented to the emergency department with suspected PTA over a ten-year period. Patients were divided into two groups; those that presented during the years prior to policy implementation and those that presented during the years following. Main outcome measures were the frequency of patients who underwent CT scanning as a part of their workup, the specialty of the ordering physician, and the treatment for suspected PTA. RESULTS: A total of 317 patients with suspected PTA were seen prior to policy implementation, with an additional 275 patients seen in the years after. The frequency of CT use was 41% (131/317) in pre-policy patients, and 28% (77/275) in post-policy patients (p = 0.004). The most common specialty of ordering physician was Pediatrics in the pre-policy patients (45%), and Otolaryngology in the post-policy patients (41%) (p = 0.0003). Of the 131 patient who underwent CT scanning before policy implementation, 36 patients (27%) required incision and drainage (I&D) of their PTA in the OR. This is in comparison to 42/77 patients (55%) in the post-policy group who underwent I&D in the OR (p < 0.0001). CONCLUSION: An institution-wide policy to decrease unnecessary imaging studies in pediatric patients resulted in a significant reduction in the use of CT imaging in the work-up for suspected PTA. Additionally, there was increase in the frequency of patients who underwent surgical intervention for their PTA after CT imaging, suggesting a more scrutinized approach to CT usage since policy implementation.


Assuntos
Política Organizacional , Otolaringologia/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Abscesso Peritonsilar/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Drenagem , Serviço Hospitalar de Emergência , Feminino , Hospitais Pediátricos , Humanos , Masculino , Abscesso Peritonsilar/cirurgia , Estudos Retrospectivos , Procedimentos Desnecessários/estatística & dados numéricos
14.
BMC Health Serv Res ; 19(1): 208, 2019 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-30940130

RESUMO

BACKGROUND: Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs. METHODS: Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes. RESULTS: Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions. CONCLUSIONS: A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.


Assuntos
Cesárea/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Feminino , Humanos , Lactente , Gravidez , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Tennessee/epidemiologia
15.
BMJ Case Rep ; 12(3)2019 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-30936331

RESUMO

Coronary artery disease managed by percutaneous coronary intervention (PCI) has been noted for profit-driven overuse medicine. Concerns mount over inappropriate use of PCI for patients in India. We describe the case of a 55-year-old Indian man who presented for a second opinion following an urgent recommendation for PCI by two cardiologists following a recent acute myocardial infarction even though the patient was symptom-free and out of the window period for primary PCI. The proposed intervention placed the patient at financial risk for insolvency. This case report highlights the challenges and consequences of inappropriate overuse of PCI. Also, we outline the current lack of shared decision-making among patients and physicians for the PCI procedure. The challenges, inherent in the assumptions that overuse of PCI is evidence-based, are discussed including recommendations for the practice of evidence based medicine for this intervention.


Assuntos
Mau Uso de Serviços de Saúde/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico , Intervenção Coronária Percutânea , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Desnecessários , Efeitos Psicossociais da Doença , Tomada de Decisões , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Índia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Satisfação do Paciente , Intervenção Coronária Percutânea/economia , Inibidores da Agregação de Plaquetas/uso terapêutico , Encaminhamento e Consulta , Resultado do Tratamento , Procedimentos Desnecessários/economia , Procedimentos Desnecessários/estatística & dados numéricos
16.
Eur Radiol ; 29(10): 5507-5516, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30887201

RESUMO

OBJECTIVES: To develop a diagnostic algorithm for positron emission tomography (PET)-detected incidental breast lesions using both breast imaging reporting and data system (BI-RADS) and maximum standardized uptake value (SUVmax) criteria. METHODS: Fifty-six PET-detected incidental breast lesions from 51 patients, which were subsequently investigated by breast ultrasound within 1 month of the PET study, constituted the study cohort and they were finally verified by tissue diagnosis or a 2-year follow-up. Based on the maximum specificity with sensitivity > 60.0% and maximum sensitivity with specificity > 60.0%, two SUVmax cutoff values were calculated at 2 and 3.7. BI-RADS ≥ 4 was considered as highly suspicious for malignancy. The diagnostic accuracies were estimated for SUVmax levels above or below the cutoff points combined with the BI-RADS suspicion level. RESULTS: Overall, 46 benign and 10 malignant lesions were studied. The diagnostic characteristics of SUVmax ≥ 2, SUVmax ≥ 3.7, and BI-RADS ≥ 4 were 80.0%, 60.0%, and 80.0% for sensitivity, 73.9%, 95.7%, and 92.7% for specificity, and 75.0%, 89.3%, and 90.2% for accuracy, respectively. When the SUVmax threshold was set at 2, combined with BI-RADS suspicion level, the sensitivity, specificity, and accuracy were 100.0%, 69.6%, and 75.0%, respectively. The results for SUVmax threshold set at 3.7 combined with BI-RADS were 90.0%, 91.3%, and 91.1% for the sensitivity, specificity, and accuracy, respectively. A diagnostic algorithm was accordingly generated. CONCLUSION: The need for biopsy should be justified in low BI-RADS lesions presenting with high SUVmax at 3.7 or higher. The biopsy of patients with high B-IRADS and low SUVmax could be preserved. KEY POINTS: • A diagnostic algorithm was developed for PET-detected incidental breast lesions using both BI-RADS and SUVmax criteria. • Diagnostic performance was calculated separately and conjunctively for SUVmax ≥ 2, SUVmax ≥ 3.7, and BI-RADS ≥ 4. • The need for biopsy can be justified in BI-RADS < 4 lesions with SUVmax ≥ 3.7. Lesions with BI-RADS < 4 and indeterminate SUVmax (2 < SUVmax < 3.7) benefit from a short-interval follow-up. BI-RADS < 4 lesions with SUVmax < 2 may confidently be scheduled for routine screening.


Assuntos
Algoritmos , Neoplasias da Mama/diagnóstico por imagem , Adulto , Idoso , Biópsia , Neoplasias da Mama/patologia , Feminino , Humanos , Interpretação de Imagem Assistida por Computador/métodos , Achados Incidentais , Pessoa de Meia-Idade , Imagem Multimodal , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Estudos Retrospectivos , Sensibilidade e Especificidade , Ultrassonografia Mamária , Procedimentos Desnecessários/estatística & dados numéricos
17.
Rev Bras Ginecol Obstet ; 41(3): 147-154, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30873565

RESUMO

OBJECTIVE: The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. METHODS: Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). RESULTS: The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS. The rate of vaginal birth after cesarean was 261 (6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. CONCLUSION: The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Cuidado Pré-Natal/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Adulto , Analgesia Obstétrica/estatística & dados numéricos , Anestesia Epidural/estatística & dados numéricos , Cesárea/estatística & dados numéricos , Saúde da Criança/estatística & dados numéricos , Feminino , Humanos , Trabalho de Parto Induzido/estatística & dados numéricos , Forceps Obstétrico/estatística & dados numéricos , Ocitócicos , Ocitocina , Gravidez , Resultado da Gravidez , Gravidez Múltipla/estatística & dados numéricos , Estudos Prospectivos , Nascimento a Termo , Emirados Árabes Unidos , Procedimentos Desnecessários/estatística & dados numéricos , Adulto Jovem
18.
Ir Med J ; 112(2): 871, 2019 02 14.
Artigo em Inglês | MEDLINE | ID: mdl-30892004

RESUMO

Aims To assess if there was a significant difference in the number of positive studies for pulmonary embolism between obese and non obese patients. Methods A retrospective analysis of all CTPAs performed in our institution over one year in patients aged 18-50 was performed. Data regarding the diagnosis of pulmonary embolism, the presence of airways disease, other significant chest findings, D dimer values and demographic data including a BMI surrogate was obtained. Results Two hundred and thirty CTPAs were performed in our institution over 12 months. Two hundred and twenty-one were included for analysis, of which 129 were male and 92 were female. Sixty-nine (31%) patients were classified as obese. Eleven (16%) of these had positive studies. One hundred and fifty-two patients were in the non obese category, of which 24 (15%) had positive studies. Conclusions We are not over imaging the obese patient, but are over imaging patients in general with suspected PE, but are exposing a significant number overall, to unnecessary radiation.


Assuntos
Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Pulmão/diagnóstico por imagem , Obesidade , Embolia Pulmonar/diagnóstico por imagem , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Adulto , Índice de Massa Corporal , Feminino , Humanos , Irlanda/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
19.
J Nepal Health Res Counc ; 16(41): 479-480, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30739926

RESUMO

The rising rate of caesarean section in urban Nepal is alarming as the lack of access for women in rural areas to emergency obstetric care, putting lives at risk. The latter is referred to as 'Too little too late'. At the same time, the sharp rise in caesarean section rates in cities presents the other extreme: "Too much too soon". The overuse of caesarean section causes harm, unnecessary costs, and misuse of health resources. Availability of private hospitals and increasing hospital childbirth may contribute to the rising rate of caesarean section. This article highlights the rising rate of caesarean section in urban Nepal. Keywords: Caesarean section; emergency obstetric care; Nepal.


Assuntos
Cesárea/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde , Humanos , Nepal/epidemiologia , Gravidez , Serviços de Saúde Rural , Procedimentos Desnecessários/estatística & dados numéricos , Serviços Urbanos de Saúde/estatística & dados numéricos
20.
Rom J Intern Med ; 57(2): 181-194, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-30730847

RESUMO

Quality of care in medicine is not necessarily proportional to quantity of care and excess is often useless or even more, potentially detrimental to our patients. Adhering to the European Federation of Internal Medicine's initiative, the Romanian Society of Internal Medicine (SRMI) launched the Choosing Wisely in Internal Medicine Campaign, aiming to cut down diagnostic procedures or therapeutics overused in our country. A Working Group was formed and from 200 published recommendations from previous international campaigns, 36 were voted as most important. These were submitted for voting to the members of the SRMI and posted on a social media platform. After the two voting rounds, the top six recommendations were established. These were: 1. Stop medicines when no further benefit is achieved or the potential harms outweigh the potential benefits for the individual patient. 2. Don't use antibiotics in patients with recent C. difficile without convincing evidence of need. 3. Don't regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result from activity. Promote early mobilization. 4. Don't initiate an antibiotic without an identified indication and a predetermined length of treatment or review date. 5. Don't prescribe opioids for treatment of chronic or acute pain for sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment. 6. Transfuse red cells for anemia only if the hemoglobin concentration is less than 7 g/dL or if the patient is hemodynamically unstable or has significant cardiovascular or respiratory comorbidity. Don't transfuse more units of blood than absolutely necessary.


Assuntos
Prescrição Inadequada/prevenção & controle , Medicina Interna/métodos , Sociedades Médicas , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Medicina Interna/normas , Medicina Interna/estatística & dados numéricos , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Romênia
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