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de Alencar JN. The troponin trap: a deep dive into incorporation and feedback sanction biases in NSTEMI diagnoses. Acta Cardiol 2024:1-3. [PMID: 38771592 DOI: 10.1080/00015385.2024.2349828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/23/2024] [Indexed: 05/22/2024]
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2
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Niksolat M, Mokhtari M, Kamalzadeh L, Nabi S. Fahr's disease with neuropsychiatric symptoms and intermittent course: a case report. Neurocase 2024:1-6. [PMID: 38757414 DOI: 10.1080/13554794.2024.2353392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
Fahr's disease is a rare neurodegenerative disorder with brain calcifications and neuropsychiatric symptoms. It can have variable phenotypic expression and intermittent symptomatology, making diagnosis challenging. In this report, we describe a young female patient presenting with symptoms of psychosis and confusion, which could be indicative of a delirium superimposed on the cerebral vulnerability associated with Fahr's disease. Notably, about two years prior, she experienced multiple episodes of tonic-clonic seizures that spontaneously resolved without pharmacological intervention. She had no previous psychiatric history. Following comprehensive investigations, other organic causes were ruled out, and Fahr's disease was diagnosed based on bilateral symmetrical brain calcifications seen on a head CT scan. Her treatment regimen encompassed antipsychotics and anticonvulsants. This case highlights the importance of considering Fahr's disease as a differential diagnosis in patients with new-onset neuropsychiatric symptoms. The case also explores the atypical early onset and intermittent nature of symptoms in the absence of a positive family history, highlighting the complexity of Fahr's disease. A multidisciplinary approach and regular follow-up are crucial for optimizing patient care and monitoring disease progression. Further research is needed to enhance our understanding of Fahr's disease and develop standardized treatment strategies for this rare condition.
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Affiliation(s)
- Maryam Niksolat
- Geriatric Mental Health Research Center, Department of Geriatric Medicine, School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Mahisa Mokhtari
- Department of Neurology, School of Medicine, Firoozabadi Clinical and Research Development Unit, Iran University of Medical Science, Tehran, Iran
| | - Leila Kamalzadeh
- Geriatric Mental Health Research Center, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Somaye Nabi
- Department of Emergency Medicine, School of Medicine, Firoozabadi Clinical and Research Development Unit, Iran University of Medical Science, Tehran, Iran
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3
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Harada Y, Otaka Y, Katsukura S, Shimizu T. Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study. BMJ Qual Saf 2024; 33:386-394. [PMID: 36690471 DOI: 10.1136/bmjqs-2022-015436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/13/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND There has been growing recognition that contextual factors influence the physician's cognitive processes. However, given that cognitive processes may depend on the physicians' specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians. OBJECTIVE This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy. METHODS We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis. RESULTS Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively. CONCLUSION Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yumi Otaka
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Shinichi Katsukura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
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Nieto-Clavijo C, Morales L, Vega APG, Cortés LJC, Chaparro-Olaya J. Challenging diagnosis of Plasmodium ovale malaria in a Colombian traveler: the importance of including P. ovale wallikeri in molecular screening. Rev Inst Med Trop Sao Paulo 2024; 66:e29. [PMID: 38747850 PMCID: PMC11095243 DOI: 10.1590/s1678-9946202466029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/06/2024] [Indexed: 05/19/2024] Open
Abstract
This study reports a challenging diagnosis of Plasmodium ovale malaria in a Colombian citizen returning from Cameroon. Initial microscopy screenings conducted at two private hospitals yielded conflicting results, with the first showing negative smears and the second diagnosing P. vivax. Subsequent microscopy examinations at two government laboratories identified P. ovale, although the routine species-specific PCR strategy was negative. PCR confirmation was finally obtained when P. ovale wallikeri primers were used. Although P. ovale is not frequently found in Colombia, there is a clear need to include both P. ovale curtisi and P. ovale wallikeri in the molecular diagnostic strategy. Such need stems primarily from their extended latency period, which affects travelers, the increasing number of African migrants, and the importance of accurately mapping the distribution of Plasmodium species in Colombia.
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Affiliation(s)
- Carlos Nieto-Clavijo
- Universidad El Bosque, Vicerrectoría de Investigaciones, Laboratorio de Parasitología Molecular, Bogotá, Colombia
| | - Liliana Morales
- Universidad El Bosque, Vicerrectoría de Investigaciones, Laboratorio de Parasitología Molecular, Bogotá, Colombia
| | | | | | - Jacqueline Chaparro-Olaya
- Universidad El Bosque, Vicerrectoría de Investigaciones, Laboratorio de Parasitología Molecular, Bogotá, Colombia
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Chockalingam L, Keniston A, McBeth L, Mutter M. A patient follow-up intervention to improve medical decision making at an internal medicine residency program. Diagnosis (Berl) 2024; 11:142-150. [PMID: 38310520 DOI: 10.1515/dx-2023-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/11/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVES Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH). METHODS Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices. RESULTS Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies. CONCLUSIONS Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.
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Affiliation(s)
- Leela Chockalingam
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Angela Keniston
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lauren McBeth
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marina Mutter
- Department of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Mullikin DR, Flanagan RP, Merkebu J, Durning SJ, Soh M. Physiologic measurements of cognitive load in clinical reasoning. Diagnosis (Berl) 2024; 11:125-131. [PMID: 38282337 DOI: 10.1515/dx-2023-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/08/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as heart rate variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress. METHODS Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level. RESULTS Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]). CONCLUSIONS Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.
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Affiliation(s)
- Dolores R Mullikin
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, USA
| | - Ryan P Flanagan
- Department of Pediatric Cardiology, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Jerusalem Merkebu
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Steven J Durning
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
| | - Michael Soh
- Department of Medicine, Center for Health Professions Education, Uniformed Services University of Health Sciences, USA
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Michelson KA, McGarghan FLE, Patterson EE, Samuels-Kalow ME, Waltzman ML, Greco KF. Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments. BMJ Qual Saf 2024; 33:293-300. [PMID: 36180208 DOI: 10.1136/bmjqs-2022-015314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/16/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions. METHODS This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status. RESULTS Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay. CONCLUSION Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, South Shore Hospital, Weymouth, Massachusetts, USA
| | - Finn L E McGarghan
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emma E Patterson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Mark L Waltzman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, South Shore Hospital, Weymouth, Massachusetts, USA
| | - Kimberly F Greco
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
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Murphy DR, Kadiyala H, Wei L, Singh H. An electronic trigger to detect telemedicine-related diagnostic errors. J Telemed Telecare 2024:1357633X241236570. [PMID: 38557263 DOI: 10.1177/1357633x241236570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The COVID-19 pandemic advanced the use of telehealth-facilitated care. However, little is known about how to measure safety of clinical diagnosis made through telehealth-facilitated primary care. METHODS We used the seven-step Safer Dx Trigger Tool framework to develop an electronic trigger (e-trigger) tool to identify potential missed opportunities for more timely diagnosis during primary care telehealth visits at a large Department of Veterans Affairs facility. We then applied the e-trigger algorithm to electronic health record data related to primary care visits during a 1-year period (1 April 2020-31 March 2021). The algorithm identified patients with unexpected visits within 10 days of an index telemedicine visit and classified such records as e-trigger positive. We then validated the e-trigger's ability to detect missed opportunities in diagnosis using chart reviews based on a structured data collection instrument (the Revised Safer Dx instrument). RESULTS We identified 128,761 telehealth visits (32,459 unique patients), of which 434 visits led to subsequent unplanned emergency department (ED), hospital, or primary care visits within 10 days of the index visit. Of these, 116 were excluded for clinical reasons (trauma, injury, or childbirth), leaving 318 visits (240 unique patients) needing further evaluation. From these, 100 records were randomly selected for review, of which four were falsely flagged due to invalid data (visits by non-providers or those incorrectly flagged as completed telehealth visits). Eleven patients had a missed opportunity in diagnosis, yielding a positive predictive value of 11%. DISCUSSION Electronic triggers that identify missed opportunities for additional evaluation could help advance the understanding of safety of clinical diagnosis made in telehealth-enabled care. Better measurement can help determine which patients can safely be cared for via telemedicine versus traditional in-person visits.
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Affiliation(s)
- Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Department of Medicine, Houston, TX, USA
| | - Himabindu Kadiyala
- Baylor College of Medicine, Department of Medicine, Houston, TX, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Department of Medicine, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Department of Medicine, Houston, TX, USA
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Harada Y, Kawamura R, Yokose M, Shimizu T, Singh H. Definitions and Measurements for Atypical Presentations at Risk for Diagnostic Errors in Internal Medicine: Protocol for a Scoping Review. JMIR Res Protoc 2024; 13:e56933. [PMID: 38526541 PMCID: PMC11002735 DOI: 10.2196/56933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/26/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Atypical presentations have been increasingly recognized as a significant contributing factor to diagnostic errors in internal medicine. However, research to address associations between atypical presentations and diagnostic errors has not been evaluated due to the lack of widely applicable definitions and criteria for what is considered an atypical presentation. OBJECTIVE The aim of the study is to describe how atypical presentations are defined and measured in studies of diagnostic errors in internal medicine and use this new information to develop new criteria to identify atypical presentations at high risk for diagnostic errors. METHODS This study will follow an established framework for conducting scoping reviews. Inclusion criteria are developed according to the participants, concept, and context framework. This review will consider studies that fulfill all of the following criteria: include adult patients (participants); explore the association between atypical presentations and diagnostic errors using any definition, criteria, or measurement to identify atypical presentations and diagnostic errors (concept); and focus on internal medicine (context). Regarding the type of sources, this scoping review will consider quantitative, qualitative, and mixed methods study designs; systematic reviews; and opinion papers for inclusion. Case reports, case series, and conference abstracts will be excluded. The data will be extracted through MEDLINE, Web of Science, CINAHL, Embase, Cochrane Library, and Google Scholar searches. No limits will be applied to language, and papers indexed from database inception to December 31, 2023, will be included. Two independent reviewers (YH and RK) will conduct study selection and data extraction. The data extracted will include specific details about the patient characteristics (eg, age, sex, and disease), the definitions and measuring methods for atypical presentations and diagnostic errors, clinical settings (eg, department and outpatient or inpatient), type of evidence source, and the association between atypical presentations and diagnostic errors relevant to the review question. The extracted data will be presented in tabular format with descriptive statistics, allowing us to identify the key components or types of atypical presentations and develop new criteria to identify atypical presentations for future studies of diagnostic errors. Developing the new criteria will follow guidance for a basic qualitative content analysis with an inductive approach. RESULTS As of January 2024, a literature search through multiple databases is ongoing. We will complete this study by December 2024. CONCLUSIONS This scoping review aims to provide rigorous evidence to develop new criteria to identify atypical presentations at high risk for diagnostic errors in internal medicine. Such criteria could facilitate the development of a comprehensive conceptual model to understand the associations between atypical presentations and diagnostic errors in internal medicine. TRIAL REGISTRATION Open Science Framework; www.osf.io/27d5m. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/56933.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Ren Kawamura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Masashi Yokose
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Japan
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Kunitomo K, Gupta A, Harada T, Watari T. The Big Three diagnostic errors through reflections of Japanese internists. Diagnosis (Berl) 2024; 0:dx-2023-0131. [PMID: 38501928 DOI: 10.1515/dx-2023-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/27/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To analyze the Big Three diagnostic errors (malignant neoplasms, cardiovascular diseases, and infectious diseases) through internists' self-reflection on their most memorable diagnostic errors. METHODS This secondary analysis study, based on a web-based cross-sectional survey, recruited participants from January 21 to 31, 2019. The participants were asked to recall the most memorable diagnostic error cases in which they were primarily involved. We gathered data on internists' demographics, time to error recognition, and error location. Factors causing diagnostic errors included environmental conditions, information processing, and cognitive bias. Participants scored the significance of each contributing factor on a Likert scale (0, unimportant; 10, extremely important). RESULTS The Big Three comprised 54.1 % (n=372) of the 687 cases reviewed. The median physician age was 51.5 years (interquartile range, 42-58 years); 65.6 % of physicians worked in hospital settings. Delayed diagnoses were the most common among malignancies (n=64, 46 %). Diagnostic errors related to malignancy were frequent in general outpatient settings on weekdays and in the mornings and were not identified for several months following the event. Environmental factors often contributed to cardiovascular disease-related errors, which were typically identified within days in emergency departments, during night shifts, and on holidays. Information gathering and interpretation significantly impacted infectious disease diagnoses. CONCLUSIONS The Big Three accounted for the majority of cases recalled by Japanese internists. The most relevant contributing factors were different for each of the three categories. Addressing these errors may require a unique approach based on the disease associations.
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Affiliation(s)
- Kotaro Kunitomo
- Department of General Medicine, 37028 NHO Kumamoto Medical Center , Kumamoto, Japan
| | - Ashwin Gupta
- Medicine Service, 20034 Veterans Affairs Ann Arbor Healthcare System , Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Taku Harada
- Department of General Medicine, 83943 Nerima Hikarigaoka Hospital , Nerima-ku, Tokyo, Japan
| | - Takashi Watari
- Medicine Service, 20034 Veterans Affairs Ann Arbor Healthcare System , Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of General Medicine, 83943 Nerima Hikarigaoka Hospital , Nerima-ku, Tokyo, Japan
- General Medicine Center, Shimane University Hospital, Izumo shi, Shimane, Japan
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Yamashita S, Tago M, Tokushima M, Tokushima Y, Hirakawa Y, Aihara H, Katsuki NE, Fujiwara M, Oda Y. Effects of a 60-Minute Lecture About Diagnostic Errors for Medical Students: A Single-Center Interventional Study. Cureus 2024; 16:e56117. [PMID: 38618404 PMCID: PMC11014750 DOI: 10.7759/cureus.56117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION The danger of diagnostic errors exists in daily medical practice, and doctors are required to avoid such errors as much as possible. Although various factors, including cognitive, system-related, and patient-related factors, are involved in the occurrence of diagnostic errors, the percentage of doctors with insufficient medical knowledge among those factors is extremely low. Therefore, lectures on diagnostic errors might also be useful for medical students without experience working as doctors. This study investigated whether a 60-minute lecture on diagnostic errors would enable Japanese medical students to consider the factors involved in diagnostic errors and how their perceptions of diagnostic errors change. METHODS AND MATERIALS This single-center interventional study was conducted in October 2022 among fourth-year medical students at the Faculty of Medicine, Saga University. A questionnaire survey was conducted before and immediately after the lecture to investigate changes in the perceptions of medical students regarding diagnostic errors. One mock case question was given on an exam the day after the lecture, and the number of responses to cognitive biases and system-related and patient-related factors involved in diagnostic errors were calculated. RESULTS A total of 83 students were analyzed. After the lecture, medical students were significantly more aware of the existence of the concept of diagnostic error, the importance of learning about it, their willingness to continue learning about it, and their perception that learning about diagnostic errors improves their clinical skills. They were also significantly less likely to feel blame or shame over diagnostic errors. The mean numbers of responses per student for cognitive bias, system-related factors, and patient-related factors were 1.9, 3.4, and 0.9, respectively. The mean number of responses per student for all factors was 5.6. CONCLUSION A 60-minute lecture on diagnostic errors among medical students is beneficial because it significantly changes their perception of diagnostic errors. The results of the present study also suggest that lectures may enable Japanese medical students to consider the factors involved in diagnostic errors.
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Affiliation(s)
- Shun Yamashita
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, JPN
| | - Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga, JPN
| | - Midori Tokushima
- Saga Medical Career Support Center, Saga University Hospital, Saga, JPN
| | | | - Yuka Hirakawa
- Department of General Medicine, Saga University Hospital, Saga, JPN
| | - Hidetoshi Aihara
- Department of General Medicine, Saga University Hospital, Saga, JPN
| | - Naoko E Katsuki
- Department of General Medicine, Saga University Hospital, Saga, JPN
| | - Motoshi Fujiwara
- Department of General Medicine, Saga University Hospital, Saga, JPN
| | - Yasutomo Oda
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, JPN
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Koskela TH, Esteva M, Mangione M, Contreras Martos S, Hajdarevic S, Högberg C, Marzo-Castillejo M, Sawicka-Powierza J, Siliņa V, Harris M, Petek D. What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences. Scand J Prim Health Care 2024; 42:123-131. [PMID: 38116949 PMCID: PMC10851834 DOI: 10.1080/02813432.2023.2296117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis. DESIGN A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data. SETTING AND SUBJECTS A primary care study, with narratives from 159 PCPs in 23 European countries. MAIN OUTCOME MEASURES PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently? RESULTS The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'. CONCLUSION (IMPLICATIONS) To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.
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Affiliation(s)
- Tuomas H. Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Center of General Practice, Tampere University Hospital, Tampere, Finland
| | - Magdalena Esteva
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | | | - Sara Contreras Martos
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Cecilia Högberg
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development Östersund, Umeå University, Umeå, Sweden
| | - Mercè Marzo-Castillejo
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | | | - Vija Siliņa
- Department of Family Medicine, Riga Stradiņš University, Riga, Latvia
| | - Michael Harris
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- College of Medicine & Health, University of Exeter, Exeter, UK
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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13
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Ayala Torres JD, Noreña Rengifo B. Fluorodeoxyglucose (FDG) Uptake in the Remnant Adrenal Gland Mimicking Tumor Recurrence in a Patient With Adrenocortical Carcinoma After Treatment With Mitotane. Cureus 2024; 16:e55486. [PMID: 38571874 PMCID: PMC10989695 DOI: 10.7759/cureus.55486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. Its diagnosis requires clinical suspicion and confirmation through laboratory and imaging studies, including computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound, as well as histological confirmation. Positron emission tomography (PET) is useful for distinguishing between benign and malignant lesions and for evaluating tumor recurrences or metastases. A case is described in which the uptake of fluorodeoxyglucose (18F-FDG) in a remnant adrenal gland could be misinterpreted as tumoral pathology. The article presents the case of a patient with ACC who, after treatment, showed increased FDG uptake in the remnant adrenal gland, which disappeared after discontinuation of treatment with mitotane. Possible explanations for this increase in FDG uptake are discussed, including the action of mitotane. In summary, it is highlighted that FDG uptake in remnant adrenal glands in patients treated with mitotane does not always indicate tumor recurrence or adrenal hypertrophy.
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Keser Z, Diehn FE, Lanzino G. Photon-Counting Detector CT Angiography in Cervical Artery Dissection. Stroke 2024; 55:e48-e49. [PMID: 38293798 DOI: 10.1161/strokeaha.123.046174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Zafer Keser
- Departments of Neurology (Z.K.), Mayo Clinic, Rochester, MN
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15
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Hodgson S, O'Mahony K, Nicholson J, Williams P. Thematic analysis of 'Prevention of Future Deaths' reports related to emergency departments in England and Wales 2013-2022. Emerg Med J 2024; 41:184-186. [PMID: 38050124 DOI: 10.1136/emermed-2023-213445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Sarah Hodgson
- Emergency Department, Raigmore Hospital, Inverness, UK
| | | | - James Nicholson
- Highland Medical Education Centre, Raigmore Hospital, Inverness, UK
- Resuscitation Research Group, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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16
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Gontarz M, Bargiel J, Gąsiorowski K, Marecik T, Szczurowski P, Zapała J, Wyszyńska-Pawelec G. "Air Sign" in Misdiagnosed Mandibular Fractures Based on CT and CBCT Evaluation. Diagnostics (Basel) 2024; 14:362. [PMID: 38396403 PMCID: PMC10888197 DOI: 10.3390/diagnostics14040362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Diagnostic errors constitute one of the reasons for the improper and often delayed treatment of mandibular fractures. The aim of this study was to present a series of cases involving undiagnosed concomitant secondary fractures in the mandibular body during preoperative diagnostics. Additionally, this study aimed to describe the "air sign" as an indirect indicator of a mandibular body fracture. METHODS A retrospective analysis of CT/CBCT scans conducted before surgery was performed on patients misdiagnosed with a mandibular body fracture within a one-year period. RESULTS Among the 75 patients who underwent surgical treatment for mandibular fractures, mandibular body fractures were missed in 3 cases (4%) before surgery. The analysis of CT/CBCT before surgery revealed the presence of an air collection, termed the "air sign", in the soft tissue adjacent to each misdiagnosed fracture of the mandibular body. CONCLUSIONS The "air sign" in a CT/CBCT scan may serve as an additional indirect indication of a fracture in the mandibular body. Its presence should prompt the surgeon to conduct a more thorough clinical examination of the patient under general anesthesia after completing the ORIF procedure in order to rule-out additional fractures.
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Affiliation(s)
- Michał Gontarz
- Department of Cranio-Maxillofacial Surgery, Jagiellonian University Medical College, 30-688 Cracow, Poland; (J.B.); (K.G.); (T.M.); (P.S.); (J.Z.); (G.W.-P.)
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17
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Kotwal S, Singh A, Tackett S, Bery AK, Omron R, Gold D, Newman-Toker DE, Wright SM. Assessing clinical reasoning skills following a virtual patient dizziness curriculum. Diagnosis (Berl) 2024; 11:73-81. [PMID: 38079609 DOI: 10.1515/dx-2023-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/09/2023] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE). METHODS All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated. RESULTS Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04). CONCLUSIONS The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amteshwar Singh
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Tackett
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anand K Bery
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Gold
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M Wright
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Harada Y, Otaka Y, Katsukura S, Shimizu T. Prevalence of atypical presentations among outpatients and associations with diagnostic error. Diagnosis (Berl) 2024; 11:40-48. [PMID: 38059495 DOI: 10.1515/dx-2023-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This study aimed to assess the prevalence of atypical presentations and their association with diagnostic errors in various diseases. METHODS This retrospective observational study was conducted using cohort data between January 1 and December 31, 2019. Consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine at a university hospital in Japan were included. Patients for whom the final diagnosis was not confirmed were excluded. Primary outcomes were the prevalence of atypical presentations, and the prevalence of diagnostic errors in groups with typical and atypical presentations. Diagnostic errors and atypical presentations were assessed using the Revised Safer Dx Instrument. We performed primary analyses using a criterion; the average score of less than five to item 12 of two independent reviewers was an atypical presentation (liberal criterion). We also performed additional analyses using another criterion; the average score of three or less to item 12 was an atypical presentation (conservative criterion). RESULTS A total of 930 patients were included out of a total of 2022 eligible. The prevalence of atypical presentation was 21.7 and 6.7 % when using liberal and conservative criteria for atypical presentation, respectively. Diagnostic errors (2.8 %) were most commonly observed in the cases with slight to moderate atypical presentation. Atypical presentation was associated with diagnostic errors with the liberal criterion for atypical presentation; however, this diminished with the conservative criterion. CONCLUSIONS An atypical presentation was observed in up to 20 % of outpatients with a confirmed diagnosis, and slight to moderate atypical presentation may be the highest risk population for diagnostic errors.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Yumi Otaka
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Shinichi Katsukura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Shimotsugagun, Tochigi, Japan
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Ali KJ, Goeschel CA, DeLia DM, Blackall LM, Singh H. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl) 2024; 11:17-24. [PMID: 37795579 DOI: 10.1515/dx-2023-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/26/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.
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Affiliation(s)
- Kisha J Ali
- MedStar Institute for Quality and Safety, Columbia, MD, USA
| | - Christine A Goeschel
- MedStar Institute for Quality and Safety, Columbia, MD, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Derek M DeLia
- Rutgers University, Bloustein School of Planning and Public Policy, New Brunswick, NJ, USA
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Kotwal S, Howell M, Zwaan L, Wright SM. Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes. J Gen Intern Med 2024:10.1007/s11606-024-08625-w. [PMID: 38277023 DOI: 10.1007/s11606-024-08625-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/09/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care. OBJECTIVE To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes. DESIGN A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022. PARTICIPANTS 12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience. APPROACH A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset. RESULTS Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care. CONCLUSIONS The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Mason Howell
- Department of Biosciences, Rice University, Houston, TX, USA
| | - Laura Zwaan
- Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, The Netherlands
| | - Scott M Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Marang-van de Mheen PJ, Thomas EJ, Graber ML. How safe is the diagnostic process in healthcare? BMJ Qual Saf 2024; 33:82-85. [PMID: 37793802 DOI: 10.1136/bmjqs-2023-016496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Perla J Marang-van de Mheen
- Safety & Security Science, Delft University of Technology, Faculty of Technology, Policy & Management, Delft, The Netherlands
- Centre for Safety in Healthcare, Delft University of Technology, Delft, The Netherlands
| | - Eric J Thomas
- Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
- The UTHealth-Memorial Hermann Center for Healthcare Quality and Safety, UTHealth, Houston, Texas, USA
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Newman-Toker DE, Nassery N, Schaffer AC, Yu-Moe CW, Clemens GD, Wang Z, Zhu Y, Saber Tehrani AS, Fanai M, Hassoon A, Siegal D. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf 2024; 33:109-120. [PMID: 37460118 PMCID: PMC10792094 DOI: 10.1136/bmjqs-2021-014130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 06/24/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Diagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. We previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. OBJECTIVE We sought to estimate the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. METHODS Cross-sectional analysis of US-based nationally representative observational data. We estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). Annual new cancers were taken from US-based registries (2014). Years were selected for coding consistency with prior literature. Disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories) were multiplied by literature-based rates to derive diagnostic errors and serious harms. We calculated uncertainty estimates using Monte Carlo simulations. Validity checks included sensitivity analyses and comparison with prior published estimates. RESULTS Annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers. Per 'Big Three' dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), we estimated total serious harms annually in the USA to be 795 000 (plausible range 598 000-1 023 000). Sensitivity analyses using more conservative assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. The 15 dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%. CONCLUSION An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Najlla Nassery
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Adam C Schaffer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Chihwen Winnie Yu-Moe
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Gwendolyn D Clemens
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yuxin Zhu
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ali S Saber Tehrani
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mehdi Fanai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ahmed Hassoon
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dana Siegal
- Candello, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
- Department of Risk Management & Analytics, Coverys, Boston, Massachusetts, USA
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Mushtaq M, Mushtaq Y, Khanna A, Javed A. An Update Summary on the Learning Sciences Within an Ophthalmic Context. Cureus 2024; 16:e53288. [PMID: 38298314 PMCID: PMC10829427 DOI: 10.7759/cureus.53288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/02/2024] Open
Abstract
Clinical reasoning, specifically diagnostic decision-making, has been a subject of fragmented literature since the 1970s, marked by diverse theories and conflicting perspectives. This article reviews the latest evidence in medical education, drawing from scientific literature, to offer ophthalmologists insights into optimal strategies for personal learning and the education of others. It explores the historical development of clinical reasoning theories, emphasising the challenges in understanding how doctors formulate diagnoses. The importance of clinical reasoning is underscored by its role in making accurate diagnoses and preventing diagnostic errors. The article delves into the dual process theory, distinguishing between type 1 and type 2 thinking and their implications for clinical decision-making. Cognitive load theory is introduced as a crucial aspect, highlighting the limited capacity of working memory and its impact on the diagnostic process. The zone of proximal development (ZPD) is explored as a framework for optimal learning environments, emphasising the importance of scaffolding and deliberate practice in skill development. The article discusses semantic competence, mental representation, and the interplay of different memory stores-semantic, episodic, and procedural-in enhancing diagnostic proficiency. Self-regulated learning (SRL) is introduced as a student-centric approach, emphasising goal setting, metacognition, and continuous improvement. Practical advice is provided for minimising cognitive errors in clinical reasoning, applying dual process theory, and considering cognitive load theory in teaching. The relevance of deliberate practice in ophthalmology, especially in a rapidly evolving field, is emphasised for continuous learning and staying updated with advancements. The article concludes by highlighting the importance of clinical supervisors in recognising and supporting trainees' self-regulated learning and understanding the principles of various teaching and learning theories. Ultimately, a profound comprehension of the science behind clinical reasoning is deemed fundamental for ophthalmologists to deliver high-quality, evidence-based care and foster critical thinking skills in the dynamic landscape of ophthalmology.
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Affiliation(s)
- Maryam Mushtaq
- College of Medicine, Luton and Dunstable Hospital, Bedfordshire Hospitals NHS Foundation Trust, Luton, GBR
| | - Yusuf Mushtaq
- Ophthalmology, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | | | - Ahmed Javed
- Vitreoretinal, Birmingham & Midland Eye Centre, Birmingham, GBR
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24
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Hajdarevic S, Högberg C, Marzo-Castillejo M, Siliņa V, Sawicka-Powierza J, Esteva M, Koskela T, Petek D, Contreras-Martos S, Mangione M, Ožvačić Adžić Z, Asenova R, Gašparović Babić S, Brekke M, Buczkowski K, Buono N, Çifçili SS, Dinant GJ, Doorn B, Hoffman RD, Kuodza G, Murchie P, Pilv L, Puia A, Rapalavicius A, Smyrnakis E, Weltermann B, Harris M. Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study. BJGP Open 2023; 7:BJGPO.2023.0029. [PMID: 37380218 DOI: 10.3399/bjgpo.2023.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.
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Affiliation(s)
- Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Cecilia Högberg
- Department of Public Health and Clinical Medicine, Education and Development Östersund, Unit of Research, Umeå University, Umeå, Sweden
| | - Mercè Marzo-Castillejo
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | - Vija Siliņa
- Department of Family Medicine, Riga Stradiņš University, Riga, Latvia
| | | | - Magadalena Esteva
- Majorca Primary Care Department, Spain
- Balearic Islands Health Research Institute (IdISBa), Balearic Islands, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Center of General Practice,Tampere University Hospital, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sara Contreras-Martos
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | | | - Zlata Ožvačić Adžić
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia
- Health Center Zagreb-Centar, Zagreb, Croatia
| | - Radost Asenova
- Department Urology and General Practice, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Mette Brekke
- Department of Health and Society, General Practice Research Unit, University of Oslo, Oslo, Norway
| | | | - Nicola Buono
- Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy
| | | | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Babette Doorn
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Robert D Hoffman
- Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Family Medicine, Maccabi Healthcare Services, Southern District, Israel
| | - George Kuodza
- Department of Family Medicine and Outpatient Care, Medical Faculty #2, Uzhhorod National University, Uzhgorod, Ukraine
| | - Peter Murchie
- Centre of Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Liina Pilv
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Aida Puia
- Department of Family Medicine, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Aurimas Rapalavicius
- Family Medicine Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Michael Harris
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- College of Medicine & Health, University of Exeter, Exeter, UK
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Stanietzky N, Bednarski B, Shafer A, Taggart MW, Peacock O, Vikram R. Rectal Adenocarcinoma Presenting as a Cervical Mass: A Case Report. Am J Case Rep 2023; 24:e941884. [PMID: 38011075 PMCID: PMC10697495 DOI: 10.12659/ajcr.941884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/24/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Invasive cervical tumors are often seen in clinical practice. However, there are multiple structures within the pelvis, and invasion of the cervix from another site must be included in the differential diagnosis. In such cases, a multidisciplinary approach is needed to define the organ of tumor origin. Ensuring proper staging and histologic analysis are critical for optimal management. CASE REPORT We present a case of a 68-year-old woman who presented to her gynecologist with painless post-menopausal vaginal bleeding. She was diagnosed with a locally aggressive cervical adenocarcinoma, which was histologically confirmed by an in-office biopsy. She was referred to the gynecologic oncology service at a tertiary care hospital for definitive management, where a thorough clinical workup was performed. Physical exam revealed that the mass had invaded the anterior rectal wall. Through a multidisciplinary approach and a repeat biopsy, she was correctly diagnosed with an invasive rectal adenocarcinoma. She was treated with neoadjuvant chemoradiotherapy and underwent curative surgery. Had she been incorrectly treated as having a primary cervical adenocarcinoma, there would have been no role for surgery. The change in the organ of primary drastically altered the patient's management and outcome. She is currently undergoing surveillance with cross-sectional imaging. CONCLUSIONS Cervical masses originating from non-gynecologic organs can be difficult to differentiate on physical exam and histologic analysis. When a mass involves the rectum, an invasive primary rectal adenocarcinoma must be included in the differential. This will have a significant impact on patient management and ultimately on patient survival.
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Affiliation(s)
- Nir Stanietzky
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Bednarski
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aaron Shafer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa W. Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raghunandan Vikram
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Arcana RI, Crișan-Dabija RA, Caba B, Zamfir AS, Cernomaz TA, Zabara-Antal A, Zabara ML, Arcana Ș, Marcu DT, Trofor A. Speaking of the "Devil": Diagnostic Errors in Interstitial Lung Diseases. J Pers Med 2023; 13:1589. [PMID: 38003904 PMCID: PMC10672616 DOI: 10.3390/jpm13111589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Interstitial lung diseases are respiratory diseases, which affect the normal lung parenchyma and can lead to significant pulmonary fibrosis, chronic respiratory failure, pulmonary hypertension, and ultimately death. Reuniting more than 200 entities, interstitial lung diseases pose a significant challenge to the clinician, as they represent rare diseases with vague and insidious respiratory symptoms. As such, there are many diagnostic errors that can appear along the journey of the patient with ILD, which leads to significant delays with implications for the prognosis and the quality of life of the patient.
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Affiliation(s)
- Raluca Ioana Arcana
- Doctoral School of the Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (R.I.A.); (A.Z.-A.); (Ș.A.)
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
| | - Radu Adrian Crișan-Dabija
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
- Department of Medical Sciences III, Pulmonology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Bogdan Caba
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Alexandra-Simona Zamfir
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
- Department of Medical Sciences III, Pulmonology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Tudor Andrei Cernomaz
- Department of Medical Sciences III, Pulmonology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
- Regional Institute of Oncology, 700483 Iasi, Romania
| | - Andreea Zabara-Antal
- Doctoral School of the Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (R.I.A.); (A.Z.-A.); (Ș.A.)
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
| | - Mihai Lucian Zabara
- Department of Surgery, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
- St. Spiridon Emergency Hospital, Clinic of Surgery (II), 700111 Iasi, Romania
| | - Ștefăniță Arcana
- Doctoral School of the Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (R.I.A.); (A.Z.-A.); (Ș.A.)
| | - Dragoș Traian Marcu
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
- Department of Medical Sciences I, Cardiology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Antigona Trofor
- Clinical Hospital of Pulmonary Diseases, 700115 Iasi, Romania; (R.A.C.-D.); (A.-S.Z.); (D.T.M.); (A.T.)
- Department of Medical Sciences III, Pulmonology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
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Bell SK, Dong J, Ngo L, McGaffigan P, Thomas EJ, Bourgeois F. Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey. BMJ Qual Saf 2023; 32:644-654. [PMID: 35121653 DOI: 10.1136/bmjqs-2021-013937] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Language barrier, reduced self-advocacy, lower health literacy or biased care may hinder the diagnostic process. Data on how patients/families with limited English-language health literacy (LEHL) or disadvantaged socioeconomic position (dSEP) experience diagnostic errors are sparse. METHOD We compared patient-reported diagnostic errors, contributing factors and impacts between respondents with LEHL or dSEP and their counterparts in the 2017 Institute for Healthcare Improvement US population-based survey, using contingency analysis and multivariable logistic regression models for the analyses. RESULTS 596 respondents reported a diagnostic error; among these, 381 reported LEHL or dSEP. After adjusting for sex, race/ethnicity and physical health, individuals with LEHL/dSEP were more likely than their counterparts to report unique contributing factors: "(No) qualified translator or healthcare provider that spoke (the patient's) language" (OR and 95% CI 4.4 (1.3 to 14.9)); "not understanding the follow-up plan" (1.9 (1.1 to 3.1)); "too many providers… but no clear leader" (1.8 (1.2 to 2.7)); "not able to keep follow-up appointments" (1.9 (1.1 to 3.2)); "not being able to pay for necessary medical care" (2.5 (1.4 to 4.4)) and "out-of-date or incorrect medical records" (2.6 (1.4 to 4.8)). Participants with LEHL/dSEP were more likely to report long-term emotional, financial and relational impacts, compared with their counterparts. Subgroup analysis (LEHL-only and dSEP-only participants) showed similar results. CONCLUSIONS Individuals with LEHL or dSEP identified unique and actionable contributing factors to diagnostic errors. Interpreter access should be viewed as a diagnostic safety imperative, social determinants affecting care access/affordability should be routinely addressed as part of the diagnostic process and patients/families should be encouraged to access and update their medical records. The frequent and disproportionate long-term impacts from self-reported diagnostic error among LEHL/dSEP patients/families raises urgency for greater prevention and supportive efforts.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joe Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Eric J Thomas
- Department of Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Fabienne Bourgeois
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Harada Y, Watari T, Nagano H, Suzuki T, Kunitomo K, Miyagami T, Aita T, Ishizuka K, Maebashi M, Harada T, Sakamoto T, Tomiyama S, Shimizu T. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. Diagnosis (Berl) 2023; 10:329-336. [PMID: 37561056 DOI: 10.1515/dx-2023-0030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES To assess the usefulness of case reports as sources for research on diagnostic errors in uncommon diseases and atypical presentations. CONTENT We reviewed 563 case reports of diagnostic error. The commonality of the final diagnoses was classified based on the description in the articles, Orphanet, or epidemiological data on available references; the typicality of presentation was classified based on the description in the articles and the judgment of the physician researchers. Diagnosis Error Evaluation and Research (DEER), Reliable Diagnosis Challenges (RDC), and Generic Diagnostic Pitfalls (GDP) taxonomies were used to assess the factors contributing to diagnostic errors. SUMMARY AND OUTLOOK Excluding three cases in that commonality could not be classified, 560 cases were classified into four categories: typical presentations of common diseases (60, 10.7 %), atypical presentations of common diseases (35, 6.2 %), typical presentations of uncommon diseases (276, 49.3 %), and atypical presentations of uncommon diseases (189, 33.8 %). The most important DEER taxonomy was "Failure/delay in considering the diagnosis" among the four categories, whereas the most important RDC and GDP taxonomies varied with the categories. Case reports can be a useful data source for research on the diagnostic errors of uncommon diseases with or without atypical presentations.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Izumo, Japan
| | - Hiroyuki Nagano
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Kotaro Kunitomo
- National Hospital Organisation Kumamoto Medical Center, Kumamoto, Japan
| | | | - Tetsuro Aita
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Japan
| | | | - Taku Harada
- Division of General Medicine, Nerima Hikarigaoka Hospital, Nerima-Ku, Tokyo
| | - Tetsu Sakamoto
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Shusaku Tomiyama
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Shimotsuga-Gun, Japan
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29
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Cogan JC, McFarland MM, May JE, Lim MY. Quality improvement approaches to heparin-induced thrombocytopenia: a scoping review. Res Pract Thromb Haemost 2023; 7:102219. [PMID: 38077807 PMCID: PMC10704520 DOI: 10.1016/j.rpth.2023.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 02/12/2024] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a relatively uncommon condition characterized by 2 exceedingly common phenomena in hospitalized patients: thrombocytopenia and heparin exposure. Consequently, HIT is frequently overdiagnosed and inappropriately treated. These issues are the focus of many quality improvement (QI) initiatives. Objectives In this scoping review, we identified and characterized all published QI studies on improving the diagnosis and management of HIT. Methods We conducted a systematic literature search through April 2022 for studies reporting on QI interventions regarding the diagnosis, treatment, and/or prevention of HIT. Results Thirty studies were included in the final review. Studies were separated into 5 groups based on the focus of the interventions: increasing HIT recognition, reducing HIT incidence, reducing HIT overdiagnosis, promoting safer HIT management, and creating HIT task forces. Nine studies focused on the implementation of 4Ts score calculator into electronic medical record orders for HIT testing, while only 1 evaluated the impact of reducing unfractionated heparin use in favor of low-molecular-weight heparin. Six studies focused on the implementation of direct thrombin inhibitor management protocols, while none evaluated the use of alternative anticoagulants in HIT management. Conclusion The bulk of published HIT QI research focused on reducing overdiagnosis and promoting safer direct thrombin inhibitor therapy, while minimal attention has been devoted to HIT prevention and the use of evidence-based alternative HIT therapies.
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Affiliation(s)
- Jacob C. Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mary M. McFarland
- Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
| | - Jori E. May
- University of Alabama at Birmingham Medicine Birmingham, Alabama, USA
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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30
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Wang Y, Bou Rjeily N, Koshorek J, Grkovski R, Aulakh M, Lin D, Solomon AJ, Mowry EM. Clinical and radiologic characteristics associated with multiple sclerosis misdiagnosis at a tertiary referral center in the United States. Mult Scler 2023; 29:1428-1436. [PMID: 37698023 DOI: 10.1177/13524585231196795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND Misdiagnosis of multiple sclerosis (MS) is common and can have harmful effects on patients and healthcare systems. Identification of factors associated with misdiagnosis may aid development of prevention strategies. OBJECTIVE To identify clinical and radiological predictors of MS misdiagnosis. METHODS We retrospectively reviewed medical records of all patients who were referred to Johns Hopkins MS Center from January 2018 to June 2019. Patients who carried a diagnosis of MS were classified as correctly diagnosed or misdiagnosed with MS by the Johns Hopkins clinician. Demographics, clinical, laboratory, and radiologic data were collected. Differences between the two groups were evaluated, and a regression model was constructed to identify predictors of misdiagnosis. RESULTS Out of 338 patients who were previously diagnosed with MS, 41 (12%) had been misdiagnosed. An alternative diagnosis was confirmed in 28 (68%) of the misdiagnosed patients; cerebrovascular disease was the most common alternate diagnosis. Characteristics associated with misdiagnosis were female sex (odds ratio (OR): 5.81 (95% confidence interval (CI): 1.60, 21.05)) and non-specific brain magnetic resonance imaging (MRI) lesions (OR: 7.66 (3.42, 17.16)). CONCLUSION Misdiagnosis is a frequent problem in MS care. Non-specific brain lesions were the most significant predictor of misdiagnosis. Interventions aimed to reduce over-reliance on imaging findings and misapplication of the McDonald criteria may prevent MS misdiagnosis.
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Affiliation(s)
- Yujie Wang
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Nicole Bou Rjeily
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacqueline Koshorek
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Risto Grkovski
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Manek Aulakh
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Doris Lin
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew J Solomon
- Department of Neurological Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Karande S, Vaideeswar P, More T. How often are heart diseases correctly diagnosed antemortem in children with fatal illnesses? A retrospective review of medical and autopsy records. J Postgrad Med 2023; 69:224-226. [PMID: 37787265 PMCID: PMC10846810 DOI: 10.4103/jpgm.jpgm_608_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/04/2023] Open
Abstract
This retrospective study analyzed the concordance level between clinical and autopsy diagnosis of heart diseases over six years. Utilizing the Goldmann classification, the concordance rate was found to be 38.1%. Major discrepancies (Class I and II) were found in 39% cases and minor (Class III and IV) in 22.9% cases.
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Affiliation(s)
- S Karande
- Department of Pediatrics), Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, Maharashtra, India
| | - P Vaideeswar
- Department of Pathology (Cardiovascular & Thoracic Division), Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, Maharashtra, India
| | - T More
- Department of Pediatrics), Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, Maharashtra, India
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Oskolkova SN. Corrigendum to "Schizophrenia: a narrative review of etiological and diagnostic issues" (Consortium Psychiatricum, 2022, Volume 3, Issue 3, doi: 10.17816/CP132). Consort Psychiatr 2023; 4:13625. [PMID: 38249534 PMCID: PMC10795942 DOI: 10.17816/cp13625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 01/23/2024] Open
Abstract
[This corrects the article DOI: 10.17816/CP132.].
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Affiliation(s)
- Sofia N. Oskolkova
- V. Serbsky National Medical Research Centre of Psychiatry and Narcology of the Ministry of Health of the Russian Federation
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33
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Zhang L, Xuan J, Li M, Zhang M, Song Y, Pan Z, Fan B, Lu L, Zhou H, Li Y. Case report: Misdiagnosis of primary mucinous cystadenoma of the testicle by ultrasound. Front Oncol 2023; 13:1206697. [PMID: 37731639 PMCID: PMC10508290 DOI: 10.3389/fonc.2023.1206697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
Testicular mucinous cystadenoma is a rare benign testicular tumor with the characteristics of being potentially malignant and showing atypical clinical symptoms; this article reports a case of a primary testicular mucinous cystadenoma misdiagnosed as testicular teratoma by ultrasound. A 69-year-old man was admitted to the hospital because of a 1-year history of left-sided testicular enlargement with scrotal swelling and no obvious abnormalities on laboratory tests. Ultrasound examination revealed solid-mass lesions in the left testicle, suggesting a high probability of teratoma, and contrast-enhanced magnetic resonance imaging (MRI) examination suggested an increased possibility of epidermoid cysts. Contrast-enhanced computed tomography (CT) and contrast-enhanced MRI of the preoperative abdomen and pelvis showed no other primary adenocarcinoma. Doctors performed radical resection of the left testicle. The postoperative pathological diagnosis was mucinous cystadenoma, and calcification as well as partially mildly atypical epithelial cells were discovered. Furthermore, there were no neoplastic lesions in the epididymis or spermatic cord. No metastatic lesions were found after 6 months postoperative follow-up, and the patient's prognosis remains good.
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Affiliation(s)
- Linlin Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jianyuan Xuan
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Manxi Li
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Mei Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Song
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ziang Pan
- Department of Pathology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Bo Fan
- Department of Urology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lin Lu
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hongyan Zhou
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yang Li
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
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Nekooghadam SM, Bozorgmehr R, Safavi-Naini SAA. Acrocyanosis and Progressive Skin Necrosis as Manifestation of Waldenstrom Macroglobulinemia Associated With Type I Cryoglobulinemia: A Case Report. INT J LOW EXTR WOUND 2023; 22:605-609. [PMID: 34166124 DOI: 10.1177/15347346211026994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Waldenstrom macroglobulinemia (WM), a rare malignant disorder, occurs as a result of abnormal proliferation of lymphocytes that produce immunoglobulin M. In rare cases, WM complicates by type I cryoglobulinemia. Type I cryoglobulinemia usually presents with cutaneous manifestations such as Raynaud's phenomenon, purpura, necrosis, and gangrene. Various medical conditions, including thrombotic events, rheumatologic disorders, and malignancies, may present with skin discoloration and necrosis. Patients suffering from malignant diseases who initially present with skin manifestations usually are misdiagnosed by physicians. Here, we describe a 72-year-old man presenting with a 6-month acrocyanosis and progressive skin necrosis who was misdiagnosed by physicians. Finally, he was diagnosed to have WM associated with type I cryoglobulinemia. Though uncommon, hematologic malignancies can present with cutaneous manifestations. In some cases, patients may manifest with skin disorders alone. Early and prompt treatment of these diseases may save the patient life, relieve patient symptoms, and increase life quality.
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Affiliation(s)
- Seyed M Nekooghadam
- Shohada-E-Tajrish Hospital, Shahid Beheshti Univesity of Medical Science, Tehran, Iran
| | - Rama Bozorgmehr
- Clinical Research Development Unit, Shohada-E-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed A A Safavi-Naini
- National Research Institute of Tuberculosis and Lung Diseases, Massih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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35
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Guntersah T, Astari YK, Rinonce HT, Hutajulu SH, Puspandari DA. The Implementation of Diagnostic Assessment in Breast Lump Cases: A Cross-Sectional Study in Sragen, Indonesia. Cureus 2023; 15:e45841. [PMID: 37750064 PMCID: PMC10518061 DOI: 10.7759/cureus.45841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 09/27/2023] Open
Abstract
Introduction Triple assessment, consisting of clinical breast examination, breast imaging, and fine-needle aspiration biopsy (FNAB), is the gold standard for breast lump diagnosis to avoid diagnostic errors. However, current diagnostic practices for breast lump cases in Indonesia are widely variable and evidence for triple assessment implementation is lacking. We aimed to explore the implementation of diagnostic assessments in breast lump cases, its influencing factors, and its association with diagnostic error. Methods This cross-sectional study consecutively recruited 364 females with breast lumps who underwent surgery in Soehadi Prijonegoro Public Hospital, Sragen, Indonesia. Data were retrospectively collected from patient's medical records. Diagnostic assessments were classified as single assessment with clinical breast examination, double assessment with clinical breast examination and breast ultrasonography (USG) or fine-needle aspiration biopsy (FNAB), and triple assessment. Diagnostic error was defined as a discrepancy between pre- and post-surgery diagnosis or repeated surgery without neoadjuvant chemotherapy. Factors associated with diagnostic assessment implementation, diagnostic error, and repeated surgery were analyzed using the chi-square test. Results The choice of diagnostic assessment was influenced by patients' age and health insurance (p<0.001). Triple assessment was only implemented in 21 (5.8%) breast lump cases. It was more frequently applied in patients ≥40 years (57.1%) and patients with contributory health insurance (76.2%). Diagnostic errors were observed in 84 cases (23.1%) and 47 patients out of them (47%) experienced repeated surgery. The implementation of diagnostic assessments was not associated with diagnostic error (p=0.257) but was significantly associated with repeated surgery in breast cancer (p<0.001). Repeated surgery rates were significantly lowered in cases receiving double assessment with FNAB (p<0.001). Conclusions The implementation of triple assessment in the local setting was very low. The choice of diagnostic assessment was influenced by patients' age and health insurance. Further, double assessment applying clinical breast examination and FNAB significantly decreased repeated surgery rates and thus may serve as an alternative to triple assessment in the limited resource setting.
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Affiliation(s)
- Toddy Guntersah
- Department of Pathological Anatomy, Soehadi Prijonegoro Public Hospital, Sragen, IDN
| | - Yufi K Astari
- Department of Internal Medicine, Division of Hematology and Medical Oncology, Dr. Sardjito General Hospital, Yogyakarta, IDN
| | - Hanggoro T Rinonce
- Department of Anatomical Pathology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, IDN
| | - Susanna H Hutajulu
- Department of Internal Medicine, Division of Hematology and Medical Oncology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, IDN
| | - Diah A Puspandari
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, IDN
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Priemer DS, Wysozan T, Zahedi F, Alrabadi N, Mesa H, Vortmeyer AO. Qualitative Comparison of Cryostat- versus Snap-Frozen Neurosurgical Intraoperative Consultations. Int J Surg Pathol 2023; 31:949-956. [PMID: 35971290 DOI: 10.1177/10668969221117987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Frozen sections (FS) are common in neurosurgery to address varied clinical concerns. Artifacts in central nervous system (CNS) FS can be severe and affect or hinder interpretation. We performed a case-control study using a semiquantitative scale: the Histologic Preservation Score (HPS), and a quantitative scale: the Ice Crystal Vacuolization Score (ICVS), to compare the histologic quality yielded by snap- versus cryostat freezing techniques. Material and Methods. All specimens were sectioned in 2 halves, one half was used for FS and the other for permanent evaluation. HPS assigns a distortion score to the FS sample using the non-frozen half as the comparator: 1 = minimal, 2 = slight, 3 = moderate, 4 & 5 = severe. The ICVS is the average size in µm of the 5 largest vacuoles/0.05 mm2, evaluated on digitized slides. Results. 86 CNS-FS were collected: 22 snap- and 64 cryostat-FS. Significant differences in HPS: 2.28 versus 2.84 (p <0.05) and ICVS 7.47 versus 14.56 (p < 0.001) were obtained for snap- versus cryostat-FS, respectively. HPS and ICVS showed a strong correlation: R2 = 0.63, p < 0.0001. Histologic distortion was worse for neuroglial than mesenchymal tissue by both methods; however, a significant difference was only observed in cryostat-FS: HPS: 3.23 versus 2.33, p < 0.001; ICVS: 16.86 μm versus 10.26 μm, p < 0.001. Conclusion. Snap-FS yields better histologic quality than cryostat-FS for CNS-FS, and the difference is more pronounced in neuroglial samples. HPS and ICVS correlate strongly, indicating that the histologic quality is inversely proportional to water-crystallization. These results may apply to other areas of surgical pathology.
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Affiliation(s)
- David S Priemer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy Wysozan
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Farhad Zahedi
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nasr Alrabadi
- Department of Pharmacology, Jordan University of Science and Technology, Al Ramtha, Irbid, Jordan
| | - Hector Mesa
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexander O Vortmeyer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Gwathmey KG, Corcia P, McDermott CJ, Genge A, Sennfält S, de Carvalho M, Ingre C. Diagnostic delay in amyotrophic lateral sclerosis. Eur J Neurol 2023; 30:2595-2601. [PMID: 37209406 DOI: 10.1111/ene.15874] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disease, and the time from symptom onset to diagnosis remains long. With the advent of disease-modifying treatments, the need to identify and diagnose ALS in a timely fashion has never been greater. METHODS We reviewed the literature to define the severity of ALS diagnostic delay, the various factors that contribute to this delay (including patient and physician factors), and the role that site of symptom onset plays in a patient's diagnostic journey. RESULTS Diagnostic delay is influenced by general practitioners' lack of recognition of ALS due to disease rarity and heterogenous presentations. As a result, patients are referred to non-neurologists, have unnecessary diagnostic testing, and may ultimately be misdiagnosed. Patient factors include their illness behavior-which impacts diagnostic delay-and their site of symptom onset. Limb-onset patients have the greatest diagnostic delay because they are frequently misdiagnosed with degenerative spine disease or peripheral neuropathy. CONCLUSION Prompt ALS diagnosis results in more effective clinical management, with earlier access to disease-modifying therapies, multidisciplinary care, and, if desired, clinical trial involvement. Due to lack of commercially available ALS biomarkers, alternative strategies to identify and triage patients who likely have ALS must be employed. Several diagnostic tools have been developed to encourage general practitioners to consider ALS and make an urgent referral to ALS specialists, bypassing unnecessary referrals to non-neurologists and unnecessary diagnostic workup.
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Affiliation(s)
- Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Philippe Corcia
- CRMR SLA, CHU Tours, Tours, France
- UMR1253 iBrain UMR, Université de Tours, INSERM, Tours, France
| | - Chris J McDermott
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Angela Genge
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Stefan Sennfält
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mamede de Carvalho
- Institute of Physiology, Instituto de Medicina Molecular João Lobo Antunes, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Bell SK, Harcourt K, Dong J, DesRoches C, Hart NJ, Liu SK, Ngo L, Thomas EJ, Bourgeois FC. Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis. BMJ Qual Saf 2023:bmjqs-2022-015793. [PMID: 37604678 PMCID: PMC10879445 DOI: 10.1136/bmjqs-2022-015793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/19/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Accurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns. METHOD We implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions. RESULTS 7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots. CONCLUSION Partnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.
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Affiliation(s)
- Sigall K Bell
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kendall Harcourt
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joe Dong
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Catherine DesRoches
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas J Hart
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stephen K Liu
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Long Ngo
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Eric J Thomas
- Department of Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
- UT Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA
| | - Fabienne C Bourgeois
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Murphy DR, Zimolzak AJ, Upadhyay DK, Wei L, Jolly P, Offner A, Sittig DF, Korukonda S, Rekha RM, Singh H. Developing electronic clinical quality measures to assess the cancer diagnostic process. J Am Med Inform Assoc 2023; 30:1526-1531. [PMID: 37257883 PMCID: PMC10436145 DOI: 10.1093/jamia/ocad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/12/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Measures of diagnostic performance in cancer are underdeveloped. Electronic clinical quality measures (eCQMs) to assess quality of cancer diagnosis could help quantify and improve diagnostic performance. MATERIALS AND METHODS We developed 2 eCQMs to assess diagnostic evaluation of red-flag clinical findings for colorectal (CRC; based on abnormal stool-based cancer screening tests or labs suggestive of iron deficiency anemia) and lung (abnormal chest imaging) cancer. The 2 eCQMs quantified rates of red-flag follow-up in CRC and lung cancer using electronic health record data repositories at 2 large healthcare systems. Each measure used clinical data to identify abnormal results, evidence of appropriate follow-up, and exclusions that signified follow-up was unnecessary. Clinicians reviewed 100 positive and 20 negative randomly selected records for each eCQM at each site to validate accuracy and categorized missed opportunities related to system, provider, or patient factors. RESULTS We implemented the CRC eCQM at both sites, while the lung cancer eCQM was only implemented at the VA due to lack of structured data indicating level of cancer suspicion on most chest imaging results at Geisinger. For the CRC eCQM, the rate of appropriate follow-up was 36.0% (26 746/74 314 patients) in the VA after removing clinical exclusions and 41.1% at Geisinger (1009/2461 patients; P < .001). Similarly, the rate of appropriate evaluation for lung cancer in the VA was 61.5% (25 166/40 924 patients). Reviewers most frequently attributed missed opportunities at both sites to provider factors (84 of 157). CONCLUSIONS We implemented 2 eCQMs to evaluate the diagnostic process in cancer at 2 large health systems. Health care organizations can use these eCQMs to monitor diagnostic performance related to cancer.
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Affiliation(s)
- Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew J Zimolzak
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, Pennsylvania, USA
| | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Preeti Jolly
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Alexis Offner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dean F Sittig
- Department of Clinical and Health Informatics, The University of Texas Health Science Center at Houston’s School of Biomedical Informatics, Houston, Texas, USA
- The UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
| | - Saritha Korukonda
- Investigator-Initiated Research Operations, Geisinger, Danville, Pennsylvania, USA
| | - Riyaa Murugaesh Rekha
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, Pennsylvania, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Hooftman J, Dijkstra AC, Suurmeijer I, van der Bij A, Paap E, Zwaan L. Common contributing factors of diagnostic error: A retrospective analysis of 109 serious adverse event reports from Dutch hospitals. BMJ Qual Saf 2023:bmjqs-2022-015876. [PMID: 37558403 DOI: 10.1136/bmjqs-2022-015876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Although diagnostic errors have gained renewed focus within the patient safety domain, measuring them remains a challenge. They are often measured using methods that lack information on decision-making processes given by involved physicians (eg, record reviews). The current study analyses serious adverse event (SAE) reports from Dutch hospitals to identify common contributing factors of diagnostic errors in hospital medicine. These reports are the results of thorough investigations by highly trained, independent hospital committees into the causes of SAEs. The reports include information from involved healthcare professionals and patients or family obtained through interviews. METHODS All 71 Dutch hospitals were invited to participate in this study. Participating hospitals were asked to send four diagnostic SAE reports of their hospital. Researchers applied the Safer Dx Instrument, a Generic Analysis Framework, the Diagnostic Error Evaluation and Research (DEER) taxonomy and the Eindhoven Classification Model (ECM) to analyse reports. RESULTS Thirty-one hospitals submitted 109 eligible reports. Diagnostic errors most often occurred in the diagnostic testing, assessment and follow-up phases according to the DEER taxonomy. The ECM showed human errors as the most common contributing factor, especially relating to communication of results, task planning and execution, and knowledge. Combining the most common DEER subcategories and the most common ECM classes showed that clinical reasoning errors resulted from failures in knowledge, and task planning and execution. Follow-up errors and errors with communication of test results resulted from failures in coordination and monitoring, often accompanied by usability issues in electronic health record design and missing protocols. DISCUSSION Diagnostic errors occurred in every hospital type, in different specialties and with different care teams. While clinical reasoning errors remain a common problem, often caused by knowledge and skill gaps, other frequent errors in communication of test results and follow-up require different improvement measures (eg, improving technological systems).
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Affiliation(s)
- Jacky Hooftman
- Department of Public and Occupational Health, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Quality of Care, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | - Ilse Suurmeijer
- Faculty of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis, Utrecht, The Netherlands
| | - Ellen Paap
- Knowledge Institute, Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Centre, Rotterdam, The Netherlands
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Pusic MV, Rapkiewicz A, Raykov T, Melamed J. Estimating the Irreducible Uncertainty in Visual Diagnosis: Statistical Modeling of Skill Using Response Models. Med Decis Making 2023; 43:680-691. [PMID: 37401184 DOI: 10.1177/0272989x231162095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND For the representative problem of prostate cancer grading, we sought to simultaneously model both the continuous nature of the case spectrum and the decision thresholds of individual pathologists, allowing quantitative comparison of how they handle cases at the borderline between diagnostic categories. METHODS Experts and pathology residents each rated a standardized set of prostate cancer histopathological images on the International Society of Urological Pathologists (ISUP) scale used in clinical practice. They diagnosed 50 histologic cases with a range of malignancy, including intermediate cases in which clear distinction was difficult. We report a statistical model showing the degree to which each individual participant can separate the cases along the latent decision spectrum. RESULTS The slides were rated by 36 physicians in total: 23 ISUP pathologists and 13 residents. As anticipated, the cases showed a full continuous range of diagnostic severity. Cases ranged along a logit scale consistent with the consensus rating (Consensus ISUP 1: mean -0.93 [95% confidence interval {CI} -1.10 to -0.78], ISUP 2: -0.19 logits [-0.27 to -0.12]; ISUP 3: 0.56 logits [0.06-1.06]; ISUP 4 1.24 logits [1.10-1.38]; ISUP 5: 1.92 [1.80-2.04]). The best raters were able to meaningfully discriminate between all 5 ISUP categories, showing intercategory thresholds that were quantifiably precise and meaningful. CONCLUSIONS We present a method that allows simultaneous quantification of both the confusability of a particular case and the skill with which raters can distinguish the cases. IMPLICATIONS The technique generalizes beyond the current example to other clinical situations in which a diagnostician must impose an ordinal rating on a biological spectrum. HIGHLIGHTS Question: How can we quantify skill in visual diagnosis for cases that sit at the border between 2 ordinal categories-cases that are inherently difficult to diagnose?Findings: In this analysis of pathologists and residents rating prostate biopsy specimens, decision-aligned response models are calculated that show how pathologists would be likely to classify any given case on the diagnostic spectrum. Decision thresholds are shown to vary in their location and precision.Significance: Improving on traditional measures such as kappa and receiver-operating characteristic curves, this specialization of item response models allows better individual feedback to both trainees and pathologists, including better quantification of acceptable decision variation.
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Affiliation(s)
- Martin V Pusic
- Department Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Amy Rapkiewicz
- Department of Pathology, NYU Long Island School of Medicine, New York, NY, USA
| | - Tenko Raykov
- College of Education, Michigan State University. East Lansing, MI, USA
| | - Jonathan Melamed
- Department of Pathology, NYU Long Island School of Medicine, New York, NY, USA
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Liberman AL, Wang Z, Zhu Y, Hassoon A, Choi J, Austin JM, Johansen MC, Newman-Toker DE. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Diagnosis (Berl) 2023; 10:225-234. [PMID: 37018487 PMCID: PMC10659025 DOI: 10.1515/dx-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023]
Abstract
Diagnostic errors in medicine represent a significant public health problem but continue to be challenging to measure accurately, reliably, and efficiently. The recently developed Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach measures misdiagnosis related harms using electronic health records or administrative claims data. The approach is clinically valid, methodologically sound, statistically robust, and operationally viable without the requirement for manual chart review. This paper clarifies aspects of the SPADE analysis to assure that researchers apply this method to yield valid results with a particular emphasis on defining appropriate comparator groups and analytical strategies for balancing differences between these groups. We discuss four distinct types of comparators (intra-group and inter-group for both look-back and look-forward analyses), detailing the rationale for choosing one over the other and inferences that can be drawn from these comparative analyses. Our aim is that these additional analytical practices will improve the validity of SPADE and related approaches to quantify diagnostic error in medicine.
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Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Justin Choi
- Department of Internal Medicine, Weill Cornell Medicine
| | - J. Matthew Austin
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine and the Armstrong Institute Center for Diagnostic Excellence
| | - Michelle C. Johansen
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - David E. Newman-Toker
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
- The Johns Hopkins Bloomberg School of Public Health, Departments of Epidemiology and Health Policy & Management
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Moral L, Mori F. Drug provocation tests in children: All that glitters is not gold. Pediatr Allergy Immunol 2023; 34:e14002. [PMID: 37622259 DOI: 10.1111/pai.14002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
A proper allergy work-up, based on the gold standard drug provocation test (DPT), usually rules out suspected drug hypersensitivity in children. These tests are generally open, given their high efficiency compared with double-blind placebo-controlled DPTs. Although their negative predictive value is excellent, no studies have calculated their positive predictive value, highly dependent on the prevalence of the disease. Most studies have found a rate of <5%-10% of true beta-lactam hypersensitivity in children. Given this low prevalence (pre-test probability), a few false-positive results can significantly reduce the estimated positive predictive value. False positives may arise from the nocebo effect during the test, including nocebo by proxy, or from observer bias, which depends on professional expertise and organizational circumstances. Some studies have found a high rate of tolerance on a second DPT in children who failed the first, but these results may be affected by the interval between the two tests, of a year or more in most cases, reflecting a loss of hypersensitivity over time. Taking into account the low rate of positive DPTs, with commonly mild reactions, we suggest confirming nonsevere positive DPTs with a second provocation performed soon after the first, especially in the case of beta-lactam antibiotics, in order to improve the diagnostic accuracy, de-label more patients, and achieve a better estimation of true drug hypersensitivity prevalence. In case of mild immediate reactions, the potential benefits of a second DPT should be carefully weighed against the risk of anaphylaxis.
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Affiliation(s)
- Luis Moral
- Pediatric Allergy and Respiratory Unit, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital, IRCCS Florence, Florence, Italy
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Nogueira GM, Rafael LK, Reichardt GS, Dall'agnol M, Pimentel SK. Comparison of tomographic reports by radiologists and non-radiologists in trauma and interferences in management in a trauma reference center. Rev Col Bras Cir 2023; 50:e20233530. [PMID: 37436284 PMCID: PMC10508664 DOI: 10.1590/0100-6991e-20233530-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE diagnostic errors during the interpretation of an imaging test by the physician can lead to increased mortality and length of hospital stay for patients. The rate of divergence in the report given by a radiologist and an Emergency Physicians (EP) can reach over 20%. The objective of this study was to compare the unofficial tomographic reports issued by EP with the official reports issued by radiologists. METHODS a cross-sectional study, in which interpretations of the exams (documented in the medical records by the EP) of all patients undergoing computed tomography (CT) of the chest, abdomen or pelvis performed in the emergency room, at an interval of 8 months, were evaluated. These data were compared with the official reports of the radiologist (gold standard). RESULTS 508 patients were included. The divergence between EP and the radiologist occurred in 27% of the cases. The most common type of divergence was the one not described by the EP, but described by the radiologist. The chance of having divergence in a case of multiple trauma is 4.93 times greater in relation to the case of only blunt trauma in one segment. A statistically relevant difference was also found in the length of stay of patients who had different interpretations of the CT scans. CONCLUSION the study found a relatively high divergence rate between the EP report and the official radiologist report. However, less than 4% of these were considered to be clinically relevant, indicating the ability of the EP to interpret it satisfactorily.
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Affiliation(s)
| | | | | | - Mateus Dall'agnol
- - Universidade Federal do Paraná, Faculdade de Medicina - Curitiba - PR - Brasil
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McBee DB, Mizu R, Hamdi AM. A Case of Severe, Difficult-to-Diagnose Legionnaires' Disease in a Young Welder. Cureus 2023; 15:e42250. [PMID: 37605706 PMCID: PMC10440048 DOI: 10.7759/cureus.42250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/23/2023] Open
Abstract
Legionellosis among welders and other metalworkers is a rare but potentially underappreciated occupational hazard. The same mechanisms that predispose welders to severe pneumonia from Streptococcus pneumoniae and Bacillus cereus may similarly predispose them to Legionella pneumophila infection. We present a case of a previously healthy, immunocompetent 31-year-old male welder presenting with three days of shortness of breath, hypoxia, high-grade fever, and blood-tinged sputum. Chest computed tomography (CT) revealed a lobar consolidation of the right middle and lower lobes. Laboratory evaluation showed borderline hyponatremia, hypophosphatemia, and elevated liver enzymes. The patient was ultimately intubated and started on broad-spectrum antibiotics. Multiple respiratory cultures were negative and Legionella urine antigen testing was also negative. Eventually, bronchial Legionella culture was positive for Legionella pneumophila, and a blood next-generation sequencing test also confirmed the diagnosis. He was extubated six days following admission and subsequently discharged.
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Affiliation(s)
- Dylan B McBee
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, USA
| | - Ruth Mizu
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, USA
| | - Ahmed M Hamdi
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, USA
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Dadlez NM, Le Clair AM, Wasima S, Mayer N, Harvey WF, Roberts K, Mazzullo J, Lominac E, Koethe BC, Weingart SN. Preventing lost-to-follow up diagnostic imaging in ambulatory care: evaluation of an electronic notification tool. BMJ Open Qual 2023; 12:e002334. [PMID: 37463784 PMCID: PMC10357715 DOI: 10.1136/bmjoq-2023-002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE Missed or cancelled imaging tests may be invisible to the ordering clinician and result in diagnostic delay. We developed an outpatient results notification tool (ORNT) to alert physicians of patients' missed radiology studies. DESIGN Randomised controlled evaluation of a quality improvement intervention. SETTING 23 primary care and subspecialty ambulatory clinics at an urban academic medical centre. PARTICIPANTS 276 physicians randomised to intervention or usual care. MAIN OUTCOME MEASURE 90-day test completion of missed imaging tests. RESULTS We included 3675 radiology tests in our analysis: 1769 ordered in the intervention group and 1906 in the usual care group. A higher per cent of studies were completed for intervention compared with usual care groups in CT (20.7% vs 15.3%, p=0.06), general radiology (19.6% vs 12.0%, p=0.02) and, in aggregate, across all modalities (18.1% vs 16.1%, p=0.03). In the multivariable regression model adjusting for sex, age and insurance type and accounting for clustering with random effects at the level of the physician, the intervention group had a 36% greater odds of test completion than the usual care group (OR: 1.36 (1.097-1.682), p=0.005). In the Cox regression model, patients in the intervention group were 1.32 times more likely to complete their test in a timely fashion (HR: 1.32 (1.10-1.58), p=0.003). CONCLUSIONS An electronic alert that notified the responsible clinician of a missed imaging test ordered in an ambulatory clinic reduced the number of incomplete tests at 90 days. Further study of the obstacles to completing recommended diagnostic testing may allow for the development of better tools to support busy clinicians and their patients and reduce the risk of diagnostic delays.
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Affiliation(s)
- Nina M Dadlez
- Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Amy M Le Clair
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Syeda Wasima
- Tufts Medical Center, Boston, Massachusetts, USA
| | - Nicole Mayer
- Tufts Medical Center, Boston, Massachusetts, USA
| | - William F Harvey
- Department of Medicine, Tufts Medicine, Burlington, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Kari Roberts
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - John Mazzullo
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Eric Lominac
- Department of Informatics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin C Koethe
- Biostatistics, Epidemiology, and Research Design (BERD) Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Saul N Weingart
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Garber A, Garabedian P, Wu L, Lam A, Malik M, Fraser H, Bersani K, Piniella N, Motta-Calderon D, Rozenblum R, Schnock K, Griffin J, Schnipper JL, Bates DW, Dalal AK. Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach. JAMIA Open 2023; 6:ooad031. [PMID: 37181729 PMCID: PMC10172040 DOI: 10.1093/jamiaopen/ooad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/04/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023] Open
Abstract
Objective To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. Materials and Methods Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers. Results Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ). Discussion A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE. Conclusions We identify challenges and offer lessons from our user-centered design process.
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Affiliation(s)
- Alison Garber
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Pamela Garabedian
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Lindsey Wu
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Alyssa Lam
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Maria Malik
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Hannah Fraser
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kerrin Bersani
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Nicholas Piniella
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Daniel Motta-Calderon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ronen Rozenblum
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kumiko Schnock
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jeffrey L Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anuj K Dalal
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Moretti D, Garay Contreras MB, Talamona MM, Quiñones ND, Rossi FE, Laudanno CD, Scolari Pasinato CM, Buncuga MG. [Pseudoascitis by giant ovaric cyst]. Rev Fac Cien Med Univ Nac Cordoba 2023; 80:156-157. [PMID: 37402307 PMCID: PMC10443420 DOI: 10.31053/1853.0605.v80.n2.27848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/15/2023] [Indexed: 07/06/2023] Open
Abstract
The term pseudoascitis is used in patients who give the false impression of ascites, with abdominal distension but without peritoneal free fluid. The case of a 66-year-old woman, hypertensive and hypothyroid with occasional alcohol consumption, who consults due to progressive abdominal distension of 6 months of evolution and diffuse percussion dullness is presented, in whom a paracentesis is performed with the wrong endorsement of examination ultrasound that reports abundant intrabdominal free fluid (Fig. 1), later finding in the CT scan of the abdomen and pelvis an expansive process of cystic appearance of 295mm x 208mm x 250mm. Left anexectomy is programmed (Fig. 2) with pathological report of mucinous ovarian cystadenoma. The case report refers to the availability of the giant ovarian cyst within the differential diagnosis of ascites. If no symptoms or obvious signs of liver, kidney, heart or malignant disease are found and / or ultrasound does not reveal typical signs of intra-abdominal free fluid (fluid in the bottom of the Morrison or Douglas sac, presence of floating free intestinal handles), a CT scan and / or an RMI should be requested before performing paracentesis, which could have potentially serious consequences.
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Affiliation(s)
- Dino Moretti
- Medico. Servicio de Clínica Médica, Sanatorio Delta..
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Cho KH, Shin MH, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y, Kim HS, Hur SH, Lee SR, Hwang JY, Oh SK, Cha KS, Jeong MH. Incidence, Relevant Patient Factors, and Clinical Outcomes of the Misdiagnosis of ST-Segment-Elevation Myocardial Infarction: Results From the Korea Acute Myocardial Infarction Registry. J Am Heart Assoc 2023:e029728. [PMID: 37345749 DOI: 10.1161/jaha.123.029728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background Data on the incidence, relevant patient factors, and clinical outcomes of the misdiagnosis of ST-segment-elevation myocardial infarction (STEMI) in the modern era of percutaneous coronary intervention are limited. Methods and Results Data from KAMIR (Korea Acute Myocardial Infarction Registry) between November 2011 and June 2020 were analyzed. Out of 28 470 patients with acute myocardial infarction, 11 796 were eventually diagnosed with STEMI following a coronary angiogram. They were classified into 2 groups: patients with an initial working diagnosis of STEMI before starting the initial treatment and patients with an initial working diagnosis of non-STEMI (misdiagnosed group). Out of 11 796 patients with a final diagnosis of STEMI, 165 (1.4%) were misdiagnosed. The door-to-angiography time in the misdiagnosed group was 5 times longer than that in the timely diagnosed group (median 220 [interquartile range {IQR}, 66-1177] versus 43 [IQR, 31-58] minutes; P<0.001). In a multivariable adjustments model, patients with a history of heart failure, atypical chest pain, anemia, or symptom-to-door time ≥4 hours had significantly higher odds, whereas those with systolic blood pressure <100 mm Hg or anterior ST elevation or left bundle-branch block on ECG had lower odds of STEMI misdiagnosis. For patients with culprit lesions in the left anterior descending artery (n=5838), the adjusted 1-year mortality risk for STEMI misdiagnosis was 1.84 (95% CI, 1.01-3.38). Conclusions Misdiagnosis of STEMI is not rare and is associated with a significant delay in coronary angiography, resulting in increased 1-year mortality for patients with culprit lesions in the left anterior descending artery.
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Affiliation(s)
- Kyung Hoon Cho
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Min-Ho Shin
- Department of Preventive Medicine Chonnam National University Medical School Gwangju Hwasun-gun South Korea
| | - Min Chul Kim
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Doo Sun Sim
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Young Joon Hong
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Ju Han Kim
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Youngkeun Ahn
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
| | - Hyo-Soo Kim
- Department of Cardiology Seoul National University Medical School Seoul South Korea
| | - Seung-Ho Hur
- Department of Cardiology Keimyung University Dongsan Medical Center Daegu South Korea
| | - Sang Rok Lee
- Department of Cardiology Chonbuk National University Medical School Jeonju South Korea
| | - Jin-Yong Hwang
- Department of Cardiology Gyeongsang National University Medical School Jinju South Korea
| | - Seok Kyu Oh
- Department of Cardiology Wonkwang University Hospital Iksan South Korea
| | - Kwang Soo Cha
- Department of Cardiology Pusan National University Medical School Busan South Korea
| | - Myung Ho Jeong
- Department of Cardiology Chonnam National University Hospital and Medical School Gwangju South Korea
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Kim JY, Oh S, Yoon M, Yong TS. Importance of Balanced Attention Toward Coronavirus Disease 2019 and Neglected Tropical Diseases. Yonsei Med J 2023; 64:351-358. [PMID: 37226561 DOI: 10.3349/ymj.2022.0656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/26/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has been spreading since 2019, causing a worldwide pandemic. Amid the COVID-19 pandemic, tuberculosis, AIDS, and malaria have adversely affected the quality of life of patients and killed millions of people. In addition, COVID-19 continues to impede the delivery of health services, including those for the control of neglected tropical diseases (NTDs). Furthermore, NTDs have been reported as possible co-pathogens among patients infected with COVID-19. However, studies regarding parasitic co-infection among these patients have been limited. This review aimed to explore and describe the cases and reports of parasitic infections in the backdrop of COVID-19 to provide comprehensive knowledge regarding this aspect. We reviewed seven cases of patients who had parasitic co-infection and tested positive for COVID-19, and summarized the literature on the importance of controlling parasitic diseases. In addition, we identified recommendations for the control of parasitic diseases under possible difficulties, such as declining funding for parasitic diseases in 2020. This review highlights the growing burden of NTDs under COVID-19 that may be caused by the deficiency of healthcare infrastructure and human resources as the main reasons. Clinicians should remain vigilant for possible co-infections with parasites in COVID-19 patients, while policymakers are urged to reinforce a balanced and long-term health strategy that addresses both NTDs and COVID-19.
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Affiliation(s)
- Ju Yeong Kim
- Department of Tropical Medicine, Institute of Tropical Medicine, Arthropods of Medical Importance Resource Bank, Yonsei University College of Medicine, Seoul, Korea
| | - Singeun Oh
- Department of Tropical Medicine, Institute of Tropical Medicine, Arthropods of Medical Importance Resource Bank, Yonsei University College of Medicine, Seoul, Korea
| | - Moonsoo Yoon
- Department of Tropical Medicine, Institute of Tropical Medicine, Arthropods of Medical Importance Resource Bank, Yonsei University College of Medicine, Seoul, Korea
| | - Tai-Soon Yong
- Department of Tropical Medicine, Institute of Tropical Medicine, Arthropods of Medical Importance Resource Bank, Yonsei University College of Medicine, Seoul, Korea.
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