126
|
Kolsanov AV, Popov NV, Ayupova IO, Ivleva AI. [Consistency of expert opinions on localization of the reference points for studying a soft tissue face profile in digital teleradiological images of the skull lateral projection]. STOMATOLOGIIA 2021; 100:49-54. [PMID: 34357728 DOI: 10.17116/stomat202110004149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of the study is to identify the consistency of expert opinions when manually identifying the reference points positions for studying the soft-tissue face profile in digital teleradiological images of the skull lateral projection. MATERIAL AND METHODS The study involved 11 orthodontists having a 1 to 8 year experience. They localized the reference points manually, using the software with image enhancement options. Each doctor processed 100 X-ray images of the skull lateral projection. Totally, 1100 positions were identified (11 parameters in 100 images). The average position of 11 manual localizations was taken as the baseline. Then, manually identified positions were automatically compared with the basic localization. RESULTS We have a good consistency of expert opinions when determining the reference points of the soft-tissue face profile. Herewith, the highest consistency of expert opinions is observed for soft-tissue reference points of the upper and lower lips (LL and EN points) with the average variation coefficients equal to 0.557726 and 0.566349 respectively; and the lowest consistency is observed for the hard tissue point Po with the average variation coefficient of 0.819904. Despite rather serious shortcomings in determining separate points (such as Or, DT, Po) in teleradiological images of the lateral skull projection, the method for determining soft-tissue profilometric reference points gives satisfactory results for more than 85.87% cases. In general, the method can be considered clinically reliable. However, the means and methods for identifying reference points require improving.
Collapse
|
127
|
Ivarsson B, Johansson A, Kjellström B. The Odyssey from Symptom to Diagnosis of Pulmonary Hypertension from the Patients and Spouses Perspective. J Prim Care Community Health 2021; 12:21501327211029241. [PMID: 34219509 PMCID: PMC8255571 DOI: 10.1177/21501327211029241] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/12/2021] [Accepted: 06/13/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION/OBJECTIVE Diagnostic delays in pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are related to increased morbidity and mortality. The risk of a delayed, or even a missed, diagnosis is high as the conditions are rare. The aim was to describe patients' and spouses' experiences of the journey from the first symptom to an established diagnosis. METHODS A secondary analysis of 31 transcripts, based on 2 primary datasets containing interviews with 17 patients and 14 spouses, was carried out and analyzed according to qualitative content analysis. RESULTS One overarching category was revealed from the content analysis; "The journey from doubt and hope to receive the diagnosis." Five subcategories were identified as: overall experiences; ignoring symptoms; seeking primary care/hospital specialty care; blame and stigma; and finding a pulmonary hypertension specialist clinic. The main finding was that both patients and spouses experienced that waiting for a diagnosis and the deteriorating state of health led to anxiety and frustration. The knowledge about rare diseases among health professionals needs to be improved to enable a timelier diagnosis and initiation of treatment. CONCLUSION Patients' and spouses' lives were negatively affected by having to search for a correct diagnosis. In order for health care to identify rare diseases earlier, a well-functioning and responsive health care system, in primary care as well as in specialist care, is needed. Symptoms like breathlessness and fatigue are often unspecific but should not be ignored. Keeping the patient and spouse in the loop, and providing information that the search for an answer might take time is essential for health care providers to create trust.
Collapse
|
128
|
de Carvalho LG, Kobayashi T, Cypriano MDS, Caran EMM, Lederman HM, Alves MTDS, Abib SDCV. Diagnostic Errors in Wilms' Tumors: Learning From Our Mistakes. Front Pediatr 2021; 9:757377. [PMID: 34760854 PMCID: PMC8573411 DOI: 10.3389/fped.2021.757377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Aim: This study aimed to analyze clinical characteristics and image findings in patients initially diagnosed with renal masses and treated on the Société Internationale d'Oncologie Pédiatrique (SIOP) 2001 protocol for Wilms tumor (WT) that eventually were diagnosed with different pathologies. Methods: We reviewed the preoperative symptoms, laboratory tests, and images of patients who were initially treated for WT and proved to have other diagnoses. Data from these patients were compared to those of the last 10 patients with WT and the last 10 patients with neuroblastoma (NBL) treated at a single institution. Results: From June 2001 to December 2020, we treated 299 patients with NBL and 194 with WT. Five patients treated with preoperative chemotherapy for WT were postoperatively diagnosed with NBL (one patient had bilateral renal masses and one with multifocal xanthogranulomatous pyelonephritis). Three underwent nephrectomy, two biopsies only, and one adrenalectomy due to intraoperative characteristics. Regarding clinical presentation, abdominal mass or swelling was very suggestive of WT (p = 0.011); pain, although very prevalent in the study group (67%), was not statistically significant, as well as intratumoral calcifications on computed tomography (CT) (67%). Urinary catecholamines were elevated in all patients mistreated for WT with the exception of the patient with pyelonephritis in which it was not collected. Conclusion: Some pathologies can be misdiagnosed as WT, especially when they present unspecified symptoms and dubious images. Diagnostic accuracy was 98.1%, which highlights the quality of the multidisciplinary team. Abdominal mass or swelling is highly suggestive of WT, especially in the absence of intratumoral calcifications on CT. If possible, urinary catecholamines should be collected at presentation as they help in the differential diagnosis of NBL.
Collapse
|
129
|
Centor RM, Heudebert AI. Learning clinical reasoning from the fictional detectives. Diagnosis (Berl) 2020; 8:dx-2020-0141. [PMID: 33554510 DOI: 10.1515/dx-2020-0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022]
Abstract
While much diagnosis literature focuses on errors, our goal is to learn how to achieve diagnostic excellence. Before the explosion of cognitive psychology studies on errors, authors of fictional detectives understood the principles of arriving at the correct diagnosis (in their case the guilty party). Using quotes from many fictional detectives, we discuss a framework for diagnostic excellence. Understanding the implications of these quotes should help aspiring diagnosis experts on their path to excellence.
Collapse
|
130
|
Karande S, Kumar S, Vaideeswar P. How often is coarctation of aorta correctly diagnosed antemortem in children with fatal illnesses? A retrospective review of medical and autopsy records. J Postgrad Med 2020; 66:169-171. [PMID: 32675455 PMCID: PMC7542064 DOI: 10.4103/jpgm.jpgm_125_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This retrospective study analyzed the level of concordance between clinical and autopsy diagnosis of coarctation of aorta over 10 years. Utilizing the Goldmann classification, the concordance rate was found to be 16%. Major discrepancies (Class I and II) were found in 56% cases and minor discrepancies (Class III and IV) in 28% cases.
Collapse
|
131
|
Liu K, Qin M, Tao K, Liang Z, Cai F, Zhao L, Peng P, Liu S, Zou J, Huang J. Identification and external validation of the optimal FIB-4 and APRI thresholds for ruling in chronic hepatitis B related liver fibrosis in tertiary care settings. J Clin Lab Anal 2020; 35:e23640. [PMID: 33146916 PMCID: PMC7891512 DOI: 10.1002/jcla.23640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND With the initially defined thresholds, the most widely used serum biomarkers for staging liver fibrosis (ie, APRI and FIB-4 scores) proved to be ineffective among patients with chronic hepatitis B virus infection (CHB). Whether optimizing the FIB-4 and APRI thresholds could improve their diagnostic accuracy requires further research. METHODS Using data of treat-naïve CHB patients from three tertiary hospitals, we explored the optimal FIB-4 and APRI thresholds to rule in liver fibrosis accurately. Subsequently, we validated the applicability of the newly defined thresholds to the CHB patients from another two tertiary hospitals. RESULTS The fibrosis stages between discovery cohort (n = 433) and the external validation cohort (n = 568) were statistically different (P < .001). When ruling in significant fibrosis and advanced fibrosis by the newly defined FIB-4 thresholds (2.25 and 3.00, respectively), 24.0% and 14.3% of patients, respectively, could be classified with excellent accuracy (PPVs of 91.3% and 80.6%, respectively; misdiagnosis rates of 6.0% and 5.4%, respectively), supported by the internal and external validation tests. Regrettably, the more accurate and robust thresholds of APRI score for ruling in significant fibrosis and advanced fibrosis could not be found. Besides, the FIB-4 and APRI scores should not be recommended for ruling in cirrhosis because of poor clinical diagnostic performance. CONCLUSION The newly defined FIB-4 thresholds for ruling in significant fibrosis and advanced fibrosis showed superior and reproducible clinical diagnostic accuracy. The well-validated threshold (≥2.25) of FIB-4 score could aid in antiviral treatment decisions for treat-naïve adult CHB patients by accurately ruling in significant fibrosis in tertiary care settings.
Collapse
|
132
|
Harada Y, Shimizu T. Delayed Diagnosis of Pulmonary Thromboembolism Due to Overfocus on COVID-19. Eur J Case Rep Intern Med 2020; 7:002002. [PMID: 33194874 DOI: 10.12890/2020_002002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 11/05/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has made it difficult for physicians to follow their usual diagnostic processes. We present the case of a 25-year-old man with adjustment disorder who developed dyspnoea. He was concerned about COVID-19, but his test result was negative. After excluding COVID-19, the physician concluded that his symptoms were related to his psychiatric condition. However, the patient was diagnosed with pulmonary thromboembolism by another physician. To avoid missing a diagnosis, physicians must practice zero-based thinking, regardless of COVID-19 concerns, and not be distracted from the patient's core problems. LEARNING POINTS During the COVID-19 pandemic, significant diagnostic errors can occur because physicians are so concerned about COVID-19 that they may ignore other diagnoses.To avoid missing a life-threatening condition during the COVID-19 pandemic, physicians must consider zero-based thinking, regardless of COVID-19 concerns, and not be distracted from the patient's core problems.Measuring vital signs after a short walk can be helpful for investigating suspected pulmonary thromboembolism.
Collapse
|
133
|
Lacson R, Gujrathi I, Healey M, Fanning K, Morisset F, Hooton S, Landman A, Eappen S, Boland GW, Khorasani R. Closing the Loop on Unscheduled Diagnostic Imaging Orders: A Systems-Based Approach. J Am Coll Radiol 2020; 18:60-67. [PMID: 33031782 PMCID: PMC7796989 DOI: 10.1016/j.jacr.2020.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/05/2022]
Abstract
Objective: To: 1) describe a System for Coordinating Orders for Radiology Exams (SCORE) which aims to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry (CPOE), 2) assess the impact of SCORE and other related factors (e.g., demographics) on rate of unscheduled orders, and 3) assess the clinical necessity of orders canceled, expired, scheduled and performed. Methods: This Institutional Review Board-approved retrospective study was conducted in a large academic institution between 10/1/2017–7/1/2019. The design and implementation of SCORE is described, including people (e.g., competencies), processes (e.g., standardized procedures) and tools (e.g., EHR interfaces, dashboard). Rate of unscheduled imaging orders was compared pre-SCORE (10/1/17–9/30/18) and post-SCORE (10/1/18–6/30/19) using chi-square analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR and factors related to order resolution were assessed via multivariable analysis. Finally, clinical necessity was manually assessed by two physicians. Results: Pre-SCORE, 52,204/607,020 exam orders were unscheduled (8.6% of orders), compared to 20,900/475,000 exam orders (4.4% of orders) post-SCORE (χ2, p<0.00001), a 49% reduction in unscheduled orders. Among 447 randomly selected orders, orders were addressed via cancellation (57%), expiration (21%), scheduling (1%) and performance (11%). Order resolution was not significantly associated with other factors. 31.9% of cancellations and 27.7% of expired orders remained clinically necessary and were attributed to scheduling and patient-related factors. Conclusion: SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled exam orders.
Collapse
|
134
|
Graves LV, Edmonds EC, Thomas KR, Weigand AJ, Cooper S, Bondi MW. Evidence for the Utility of Actuarial Neuropsychological Criteria Across the Continuum of Normal Aging, Mild Cognitive Impairment, and Dementia. J Alzheimers Dis 2020; 78:371-386. [PMID: 32986674 PMCID: PMC7683095 DOI: 10.3233/jad-200778] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background: Research suggests that actuarial neuropsychological criteria improve the accuracy of mild cognitive impairment (MCI) diagnoses relative to conventional diagnostic methods. Objective: We sought to examine the utility of actuarial criteria relative to consensus diagnostic methods used in the National Alzheimer’s Coordinating Center (NACC) Uniform Data Set (UDS), and more broadly across the continuum of normal aging, MCI, and dementia. Methods: We compared rates of cognitively normal (CN), MCI, and dementia diagnoses at baseline using actuarial versus consensus diagnostic methods in 1524 individuals from the NACC UDS. Results: Approximately one-third (33.59%) of individuals diagnosed as CN and more than one-fifth (22.03%) diagnosed with dementia based on consensus methods, met actuarial criteria for MCI. Many participants diagnosed with MCI via consensus methods also appeared to represent possible diagnostic errors. Notably, the CNa/CNc group (i.e., participants diagnosed as CN based on both actuarial [a] and consensus [c] criteria) had a lower proportion of apolipoprotein E ɛ4 carriers than the MCIa/MCIc group, which in turn had a lower proportion of ɛ4 carriers than the dementia (Dem)a/Demc group. Proportions of ɛ4 carriers were comparable between the CNa/CNc and CNa/MCIc, MCIa/MCIc and MCIa/CNc, MCIa/MCIc and MCIa/Demc, and Dema/Demc and Dema/MCIc groups. These results were largely consistent with diagnostic agreement/discrepancy group comparisons on neuropsychological performance. Conclusion: The present results extend previous findings and suggest that actuarial neuropsychological criteria may enhance diagnostic accuracy relative to consensus methods, and across the wider continuum of normal aging, MCI, and dementia. Findings have implications for both clinical practice and research.
Collapse
|
135
|
Khan A, Abedi V, Li J, Malik MT, Esch M, Zand R. CADASIL vs. Multiple Sclerosis: Is It Misdiagnosis or Concomitant? A Case Series. Front Neurol 2020; 11:860. [PMID: 33013620 PMCID: PMC7500095 DOI: 10.3389/fneur.2020.00860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/07/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction: Cerebral autosomal dominant arteriopathy and subcortical infarct leukoencephalopathy (CADASIL) is the most common form of hereditary stroke caused by a mutation in the NOTCH3 gene located on the short arm of chromosome 19. A small number of published reports describe CADASIL patients who were initially diagnosed as multiple sclerosis. Although it was previously indicated that there was no association between NOTCH3 mutations and multiple sclerosis, the involvement of autoimmune mechanisms among patients with CADASIL has been hypothesized. Case Presentation: Case 1 is a middle-aged woman with initial diagnoses of multiple sclerosis (MS) and myelitis that continued to progress despite treatment with disease-modifying agents. She had occasional migraines, transient blurred vision, and multiple lacunar infarcts. She continued treatment for about 15 years with no significant alleviation and progressive changes on brain MRI; genetic testing was ordered which showed NOTCH3 mutation, and diagnosis was changed to CADASIL with subsequent revision of treatment course. However, the presence of myelitis in this patient is unusual and may raise the question of a concurrent autoimmune process. Case 2 is a woman presenting with vertigo and paresthesia and diagnosed with MS based on an initial brain MRI showing biventricular white matter hyperintensities; however, she was not started on any disease-modifying agents. Her symptoms were reevaluated by a neurologist, and genetic testing was performed for NOTCH 3. Case 3 is a young woman with a history of migraines who initially presented with numbness and gait ataxia which later progressed to speech difficulty and memory loss. A diagnosis of MS was established which was later changed to CADASIL. Conclusion: Since CADASIL is a rare disease, it is imperative to raise awareness of its unique clinical condition as well as variation in its clinical presentations. It is crucial that the overlapping symptoms between MS and CADASIL be thoroughly examined to avoid misdiagnosis and treatment complications. The involvement of autoimmune mechanisms in CADASIL and the role of NOTCH3 gene mutations in provoking an autoimmune process should be further investigated.
Collapse
|
136
|
Avelino-Silva TJ, Steinman MA. Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey. SAO PAULO MED J 2020; 138:359-367. [PMID: 32935740 PMCID: PMC9673862 DOI: 10.1590/1516-3180.0471.r1.05032020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/05/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays. OBJECTIVES To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults. DESIGN AND SETTING Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey. METHODS Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether. RESULTS Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality. CONCLUSION One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities.
Collapse
|
137
|
Velázquez Martín M, Montero Cabezas JM, Huertas S, Nuche J, Albarrán A, Delgado JF, Alonso S, Sarnago F, Arribas F, Escribano Subias P. Clinical relevance of adding intravascular ultrasound to coronary angiography for the diagnosis of extrinsic left main coronary artery compression by a pulmonary artery aneurysm in pulmonary hypertension. Catheter Cardiovasc Interv 2020; 98:691-700. [PMID: 32790221 DOI: 10.1002/ccd.29194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/23/2020] [Accepted: 07/19/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We sought to assess the clinical value of adding intravascular ultrasound (IVUS) evaluation to coronary angiography (CA) to guide extrinsic left main coronary artery (LMCA) compression diagnosis and treatment in pulmonary hypertension (PH). BACKGROUND LMCA compression due to a pulmonary artery aneurysm (PAA) is a severe complication of PH. Although guidelines encourage the use of IVUS for LMCA disease evaluation, it has hardly been used in this scenario. METHODS We analyzed morbimortality of type 1 and 4 PH patients with clinically suspected LMCA compression by a PAA between 2010 and 2018 in a reference unit. LMCA compression was prospectively assessed with CA ± IVUS. Angiographic-LMCA compression was considered conclusive when LMCA stenosis>50% was present in four predetermined projections; inconclusive, when LMCA stenosis>50% was present in <4 projections and negative if no stenosis>50% was present. Patients with conclusive and inconclusive CA underwent IVUS. IVUS-LMCA compression was defined as systolic minimum lumen area < 6 mm2 . RESULTS LMCA compression was suspected in 23/796 patients (3%). CA was conclusive for compression in 7(30.5%), inconclusive in 9(39%), and negative in 7(30.5%). IVUS confirmed LMCA compression in 6/7(86%) patients with conclusive CA and in 2/9(22%) with inconclusive CA. Patients fulfilling IVUS criteria for LMCA compression underwent stent implantation. At 20 months follow-up a composite end-point of death, stent restenosis/thrombosis, or lung transplant was reported in three patients (13%). CONCLUSIONS CA can misdiagnose LMCA extrinsic compression. IVUS discriminates better whether significant compression by a PAA exists or not, avoiding unnecessary LMCA stenting. Patients treated following this strategy show a low rate of major clinical events at 20 months follow-up.
Collapse
|
138
|
Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: state of the science. ACTA ACUST UNITED AC 2020; 8:51-65. [PMID: 32706749 DOI: 10.1515/dx-2020-0045] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/18/2020] [Indexed: 12/15/2022]
Abstract
Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.
Collapse
|
139
|
Wang N, Atkins ER, Salam A, Moore MN, Sharman JE, Rodgers A. Regression to the mean in home blood pressure: Analyses of the BP GUIDE study. J Clin Hypertens (Greenwich) 2020; 22:1184-1191. [PMID: 32634288 DOI: 10.1111/jch.13933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 11/27/2022]
Abstract
The aim of our study was to estimate the size of regression to the mean with home blood pressure (BP) monitoring and compare with that for office BP. Office and home BP measures were obtained from the BP GUIDE (value of central Blood Pressure for GUIDing managEment for hypertension) study, in which 286 patients had BP measured every 3 months for 12 months. Patients were categorized by 10 mm Hg strata of baseline BP, and regression to the mean measures was calculated for home and office BP. High baseline home BP readings tended to be lower on long-term follow-up, and low baseline readings tended to be higher. For example, patients in the group with mean baseline home systolic BP ≥ 150 mm Hg had a mean baseline systolic BP of 156 mm Hg, which fell to 143 mm Hg at 12 months; and patients in the group with mean baseline home systolic BP < 120 mm Hg had a mean baseline systolic BP of 113 mm Hg which rose to 120 mm Hg at 12 months. Similar patterns were seen in intervention and control groups, and for diastolic BP. The regression dilution ratio for home systolic BP and diastolic BP was 0.52 and 0.64, respectively, compared to 0.40 and 0.55 for office systolic BP and diastolic BP, respectively. Home BP is subject to regression to the mean to a similar degree as office BP. These findings have implications for the diagnosis and management of hypertension using home BP.
Collapse
|
140
|
Jenkins P, Rogers L, Coleman M, Freeman S. Ultrasound appearance of SURGICEL® Absorbable Hemostat (oxidised cellulose) following laparoscopic resection of a splenic cyst - A potential diagnostic peril. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2020; 28:124-130. [PMID: 32528548 DOI: 10.1177/1742271x20911411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/15/2020] [Indexed: 11/15/2022]
Abstract
We present the case of a 14 year old who underwent laparoscopic marsupialisation of a splenic cyst. Postoperative ultrasound demonstrated an echogenic collection in the surgical bed that was initially misdiagnosed as an infected collection/abscess due to its sonographic appearances but was finally correctly identified as haemostatic material that had been packed into the surgical cavity. We subsequently constructed a tissue phantom containing a compressed ball of SURGICEL (r) Absorbable Hemostat and demonstrated that it showed identical sonographic appearances. Haemostatic agents such as oxidised cellulose are often packed within the operative bed to control microvascular haemorrhage. These agents can be observed on a variety of postoperative imaging modalities, in particular ultrasound and computed tomography, and may cause diagnostic error. The critical importance of understanding the details of the surgical procedure and effective communication between the surgical team and ultrasound practitioner is emphasised to minimise the risk of misdiagnosis and unnecessary further imaging and radiological/surgical intervention.
Collapse
|
141
|
False-Positive Malignant Diagnosis of Nodule Mimicking Lesions by Computer-Aided Thyroid Nodule Analysis in Clinical Ultrasonography Practice. Diagnostics (Basel) 2020; 10:diagnostics10060378. [PMID: 32517227 PMCID: PMC7345888 DOI: 10.3390/diagnostics10060378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/17/2022] Open
Abstract
This study aims to test computer-aided diagnosis (CAD) for thyroid nodules in clinical ultrasonography (US) practice with a focus towards identifying thyroid entities associated with CAD system misdiagnoses. Two-hundred patients referred to thyroid US were prospectively enrolled. An experienced radiologist evaluated the thyroid nodules and saved axial images for further offline blinded analysis using a commercially available CAD system. To represent clinical practice, not only true nodules, but mimicking lesions were also included. Fine needle aspiration biopsy (FNAB) was performed according to present guidelines. US features and thyroid entities significantly associated with CAD system misdiagnosis were identified along with the diagnostic accuracy of the radiologist and the CAD system. Diagnostic specificity regarding the radiologist was significantly (p < 0.05) higher than when compared with the CAD system (88.1% vs. 40.5%) while no significant difference was found in the sensitivity (88.6% vs. 80%). Focal inhomogeneities and true nodules in thyroiditis, nodules with coarse calcification and inspissated colloid cystic nodules were significantly (p < 0.05) associated with CAD system misdiagnosis as false-positives. The commercially available CAD system is promising when used to exclude thyroid malignancies, however, it currently may not be able to reduce unnecessary FNABs, mainly due to the false-positive diagnoses of nodule mimicking lesions.
Collapse
|
142
|
Liberman AL, Navi BB, Esenwa CC, Zhang C, Song J, Cheng NT, Labovitz DL, Kamel H, Merkler AE. Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department. Stroke 2020; 51:1876-1878. [PMID: 32295512 DOI: 10.1161/strokeaha.120.029390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Cervicocephalic artery dissection is an important cause of stroke. The clinical presentation of dissection can resemble that of benign neurological conditions leading to delayed or missed diagnosis. Methods- We performed a retrospective cohort study using statewide administrative claims data from all Emergency Department visits and admissions at nonfederal hospitals in Florida from 2005 to 2015 and New York from 2006 to 2015. Using validated International Classification of Diseases, Ninth Revision, CM codes, we identified adult patients hospitalized for cervicocephalic artery dissection. We defined probable misdiagnosis of dissection as having an Emergency Department treat-and-release visit for symptoms or signs of dissection, including headache, neck pain, and focal neurological deficits in the 14 days before dissection diagnosis. Multivariable logistic regression was used to compare adverse clinical outcomes in patients with and without probable misdiagnosis. Results- Among 7090 patients diagnosed with a dissection (mean age 52.7 years, 44.9% women), 218 (3.1% [95% CI, 2.7%-3.5%]) had a preceding probable Emergency Department misdiagnosis. After adjustment for demographics and vascular risk factors, there were no differences in rates of stroke (odds ratio, 0.82 [95% CI, 0.62-1.09]) or in-hospital death (odds ratio, 0.26 [95% CI, 0.07-1.08]) between dissection patients with and without a probable misdiagnosis at index hospitalization. Conclusions- We found that ≈1 in 30 dissection patients was probably misdiagnosed in the 2 weeks before their diagnosis.
Collapse
|
143
|
Carayon P, Hoonakker P, Hundt AS, Salwei M, Wiegmann D, Brown RL, Kleinschmidt P, Novak C, Pulia M, Wang Y, Wirkus E, Patterson B. Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. BMJ Qual Saf 2020; 29:329-340. [PMID: 31776197 PMCID: PMC7490974 DOI: 10.1136/bmjqs-2019-009857] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/11/2019] [Accepted: 11/05/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway. MATERIALS AND METHODS We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS). RESULTS Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx. CONCLUSIONS This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety.
Collapse
|
144
|
Magnussen AP, Watura C, Torr N, Walker M, Amiras D, Griffiths D. Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre. BMJ Open Qual 2020; 9:bmjoq-2018-000550. [PMID: 32193195 PMCID: PMC7101033 DOI: 10.1136/bmjoq-2018-000550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/09/2020] [Accepted: 02/16/2020] [Indexed: 11/12/2022] Open
Abstract
Background A high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome. Objective To identify factors contributing to missed diagnosis and propose solutions. Methods A local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed. Results The findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury. Discussion As a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.
Collapse
|
145
|
Stonys R, Banys V, Vitkus D, Lima-Oliveira G. Can chewing gum be another source of preanalytical variability in fasting outpatients? EJIFCC 2020; 31:28-45. [PMID: 32256287 PMCID: PMC7109498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In the daily laboratory practice, there are patients coming to blood collection sites chewing sugar-free gum, considering it irrelevant to laboratory tests. The aim of this study was to evaluate whether a sugar-free chewing gum can interfere with laboratory tests. METHODS We studied 22 healthy volunteers. After a 12-hour overnight fasting, the first blood sample was collected between 8:00 and 8:30 a.m. Then, immediately after the first venous blood collection, the subjects started chewing the gum (declared sugar-free) for 20 min. Subsequent venous blood samples were collected at 1, 2, and 4 hours after chewing the gum. Significant differences between samples were assessed by the Wilcoxon ranked-pairs test. RESULTS Among all the results, statistically significant differences (p < 0.05) between basal and × hours after chewing sugar-free gum were observed for the following parameters: cortisol, insulin, C-peptide, triglycerides, uric acid, urea, amylase, alanine aminotransferase, lipase, creatine kinase, total bilirubin, direct bilirubin, phosphate, iron, potassium, thyroid stimulating hormone, red blood cell count, hematocrit, hemoglobin, mean cell volume, red cell distribution width, white blood cell count, lymphocytes, neutrophils, and eosinophils; whereas, coagulation tests were not impacted by chewing sugar-free gum. CONCLUSIONS We recommend instructing the patients to avoid the use of chewing gum before blood collection for laboratory tests.
Collapse
|
146
|
Naides SJ, Genzen JR, Abel G, Bashleben C, Ansari MQ. Antinuclear Antibodies Testing Method Variability: A Survey of Participants in the College of American Pathologists' Proficiency Testing Program. J Rheumatol 2020; 47:1768-1773. [PMID: 32173652 DOI: 10.3899/jrheum.190933] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was conducted to determine the spectrum of laboratory practices in antinuclear antibody (ANA) test target, performance, and result reporting. METHODS A questionnaire on ANA testing was distributed by the Diagnostic Immunology and Flow Cytometry Committee of the College of American Pathologists (CAP) to laboratories participating in the 2016 CAP ANA proficiency survey. RESULTS Of 5847 survey kits distributed, 1206 (21%) responded. ANA screening method varied: 55% indirect immunofluorescence assay, 21% ELISA, 12% multibead immunoassay, and 18% other methods. The name of the test indicated the method used in only 32% of laboratories; only 39% stated the method used on the report. Of 644 laboratories, 80% used HEp-2 cell substrate, 18% HEp-2000 (HEp-2 cell line engineered to overexpress SSA antigen, Ro60), and 2% other. Slides were prepared manually (67%) or on an automated platform (33%) and examined by direct microscopy (84%) or images captured by an automated platform (16%). Only 50% reported a positive result at the customary 1:40 dilution. Titer was reported to endpoint routinely by 43%, only upon request by 23%, or never by 35%. Of the laboratories, 8% did not report dual patterns. Of those reporting multiple patterns, 23% did not report a titer with each pattern. CONCLUSION ANA methodology and practice, and test naming and reporting varies significantly between laboratories. Lack of uniformity in testing and reporting practice and lack of transparency in communicating the testing method may misdirect clinicians in their management of patients.
Collapse
|
147
|
Integration of Peer Review in PACS Results in a Marked Increase in the Discrepancies Reported. AJR Am J Roentgenol 2020; 214:613-617. [PMID: 31846375 DOI: 10.2214/ajr.19.21952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The objective of this article is to assess the impact of integrating peer review in PACS on the reporting of discrepancies. Our hypothesis is that a PACS-integrated machine-randomized and semiblinded peer review tool leads to an increase in discrepancies reported. MATERIALS AND METHODS. A PACS tool was implemented to prompt radiologists to perform peer review of prior comparison studies in a randomized fashion. The reviewed radiologist's name was omitted from the prior report in PACS. Before this implementation, radiologists entered peer reviews directly on the RADPEER website. Three academic subspecialty sections comprising 24 radiologists adopted the tool (adopters group). Three sections comprising 14 radiologists did not adopt the tool (nonadopters group). Peer review submissions were analyzed for 4 months before and 4 months after the implementation. The mean rate of significant discrepancies (RADPEER score 2b or higher) reported per radiologist was calculated and the discrepancy rates of the periods before and after the implementation were compared. RESULTS. The mean significant discrepancy rate reported per radiologist in the adopters group increased from 0.19% ± 0.46% (SD) before the implementation to 0.93% ± 1.45% after implementation (p = 0.01). No significant discrepancies were reported by the nonadopters group in either period. CONCLUSION. In this single institutional retrospective analysis, integrating peer review in PACS resulted in a fivefold increase in reported significant discrepancies. These results suggest that peer review data are influenced by the design of the tool used including PACS integration, randomization, and blinding.
Collapse
|
148
|
Abstract
The aim of the study was to systematically characterize the interference of biotin on thyroid function tests and biotin washout periods.Ten healthy adults were recruited with administration of 5 and 10 mg/d biotin for 7 days. Analyte concentrations of thyroid function tests were measured at baseline prior to starting biotin and from 2 hours to 2 days after withdrawal of 5 and 10 mg/d biotin. The outcomes were compared the baseline with the several points after taking biotin at Roche cobas e602, Beckman UniCel DxI 800, and Abbott Architect 2000 immunoassay platforms, respectively.Ingesting 5 or 10 mg/d of biotin for 7 days could produce positive or negative interference among the thyroid function tests at Roche cobas e602 and Beckman UniCel DxI 800 systems, but no interference on Abbott Architect 2000. Interference duration of 5 mg/d biotin for Roche cobas e602 and Beckman UniCel DxI 800 of thyroid function tests lasted for 8 hours, while 10 mg/d biotin interfered with Roche cobas e602 or Beckman UniCel DxI 800 for 1 day or 2 days.This study provides valuable guidance on biotin washout periods at doses common in over-the-counter supplements necessary to avoid false assay results.Trial registration: ChiCTR1800020472.
Collapse
|
149
|
Bottini PV, Garlipp CR, Lima PRM, Brito IT, Carvalho LMG. Are patients adequately informed about procedures for 24-h urine collection? Clin Chem Lab Med 2020; 58:e32-e35. [PMID: 31352432 DOI: 10.1515/cclm-2019-0368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/11/2019] [Indexed: 11/15/2022]
|
150
|
Isbell LM, Tager J, Beals K, Liu G. Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety. BMJ Qual Saf 2020; 29:1-2. [PMID: 31988259 DOI: 10.1136/bmjqs-2019-010110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 12/26/2019] [Accepted: 12/31/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Emergency department (ED) physicians and nurses frequently interact with emotionally evocative patients, which can impact clinical decision-making and behaviour. This study introduces well-established methods from social psychology to investigate ED providers' reported emotional experiences and engagement in their own recent patient encounters, as well as perceived effects of emotion on patient care. METHODS Ninety-four experienced ED providers (50 physicians and 44 nurses) vividly recalled and wrote about three recent patient encounters (qualitative data): one that elicited anger/frustration/irritation (angry encounter), one that elicited happiness/satisfaction/appreciation (positive encounter), and one with a patient with a mental health condition (mental health encounter). Providers rated their emotions and engagement in each encounter (quantitative data), and reported their perception of whether and how their emotions impacted their clinical decision-making and behaviour (qualitative data). RESULTS Providers generated 282 encounter descriptions. Emotions reported in angry and mental health encounters were remarkably similar, highly negative, and associated with reports of low provider engagement compared with positive encounters. Providers reported their emotions influenced their clinical decision-making and behaviour most frequently in angry encounters, followed by mental health and then positive encounters. Emotions in angry and mental health encounters were associated with increased perceptions of patient safety risks; emotions in positive encounters were associated with perceptions of higher quality care. CONCLUSIONS Positive and negative emotions can influence clinical decision-making and impact patient safety. Findings underscore the need for (1) education and training initiatives to promote awareness of emotional influences and to consider strategies for managing these influences, and (2) a comprehensive research agenda to facilitate discovery of evidence-based interventions to mitigate emotion-induced patient safety risks. The current work lays the foundation for testing novel interventions.
Collapse
|