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1.
Purpose of review
Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management.Recent findings
The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk.Summary
International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).2.
Michael Sighinolfi Susan Y. Quan Yvonne Lee Alvaro Ibaseta Kimberly Pham Monica M. Dua George A. Poultsides Brendan C. Visser Jeffery A. Norton Walter G. Park 《Digestive diseases and sciences》2017,62(3):626-632
Background
The aim of this study was to compare the American Gastroenterological Association guidelines (AGA criteria), the 2012 (Fukuoka criteria), and 2006 (Sendai criteria) International Consensus Guidelines for the diagnosis of advanced pancreatic cystic neoplasms.Methods
All patients who underwent surgical resection of a pancreatic cyst from August 2007 through January 2016 were retrospectively analyzed at a single tertiary academic center. Relevant clinical and imaging variables along with pathology results were collected to determine appropriate classification for each guideline. Advanced pancreatic cystic neoplasms were defined by the presence of either high-grade dysplasia or cystic adenocarcinoma. Diagnostic accuracy was measured by ROC analysis.Results
A total of 209 patients were included. Both the AGA and Fukuoka criteria had a higher diagnostic accuracy for advanced neoplastic cysts than the Sendai criteria: AGA ROC 0.76 (95% CI 0.69–0.81), Fukuoka ROC 0.78 (95% CI 0.74–0.82), and Sendai ROC 0.65 (95% CI 0.61–0.69) (p < 0.0001). There was no difference between the Fukuoka and the AGA criteria. While the sensitivity was higher in the Fukuoka criteria compared to the AGA criteria (97.7 vs. 88.6%), the specificity was higher in the AGA criteria compared to the Fukuoka criteria (62.4 vs. 58.2%).Conclusions
In a surgical series of patients with pancreatic cysts, the AGA and Fukuoka criteria had superior diagnostic accuracy for advanced neoplastic cysts compared to the original Sendai criteria.3.
Masayuki Itabashi Anna Nasierowska-Guttmejer Tadakazu Shimoda Przemysław Majewski Witold Rezner Katarzyna Sikora Ewa Śrutek Katarzyna Stęplewska Jarosław Swatek Justyna Szumilo Agnieszka Wierzchniewska-Ławska Lech Wronecki Ewa Zembala-Nożyńska Tomio Arai Masahiro Fujita Hiroshi Kawachi Masamitsu Unakami Toshiro Kamoshida 《Esophagus》2017,14(4):333-342
Background
There are differences in the histological diagnostic criteria for early stage gastrointestinal carcinoma between Western and Japanese pathologists. Western histological criteria of carcinoma are “presence of stromal invasion of neoplastic cells”, while Japanese criteria are “the degree of cytological and structural abnormality of neoplastic cells, regardless of stromal invasion”. The aim of the present study is to clarify and review the present status of the Western and Japanese histological criteria of early stage esophageal squamous cell carcinoma (SCC) and also to clarify their significance and accuracy.Methods
Twenty-nine Polish, German, and Japanese pathologists participated in this study. A total of 18 histological slides of biopsy, endoscopic submucosal dissection (ESD), and surgical resection of esophageal squamous lesions were diagnosed using a virtual slide system.Results
Most of noninvasive (intraepithelial) carcinomas diagnosed by Japanese pathologists were diagnosed as high- or low-grade dysplasia (intraepithelial neoplasia) or reactive atypia by the majority of Polish and German pathologists. Diagnoses of not only high-grade dysplasia but also low-grade dysplasia or reactive lesion by Western criteria were given for many biopsy specimens of cases in which the corresponding ESD or surgical specimens showed definite stromal invasion.Conclusion
There still exist differences in the histological diagnostic criteria for early stage esophageal carcinoma between Western and Japanese pathologists. The Japanese diagnostic criteria could improve agreement of diagnoses between biopsy and resected specimens of esophageal SCC. Moreover, diagnostic approaches using Western criteria may cause delay in the early diagnosis and treatment of esophageal SCC.4.
Background
The prognosis of specific subgroups of patients has been significantly improved by a personalized medicine due to histological differentiation, discovery of new oncogene driver mutations in adenocarcinomas and the introduction of targeted therapies.Objective
Minimally invasive endoscopic methods as well as surgical procedures are available for obtaining histological and cytological material for molecular diagnostics. The various diagnostic options with their advantages and disadvantages are described.Material and methods
A literature search was carried out in PubMed.Results
In every patient it should be possible for clinically practical reasons to perform molecular diagnostic investigations on biopsies, which are as small as possible. Endoscopic transbronchial needle aspiration (TBNA) has a high sensitivity and represents the diagnostic method of choice. If radiologically suspicious mediastinal lymph nodes are present and the cytological result is negative, surgical evaluation is still necessary.Discussion
In the future the aim will be to find further molecular alterations that make a targeted therapy possible and which can be used as prognostic biomarkers or to predict therapy response. Research into entirely noninvasive methods, such as analysis of circulating tumor cells is ongoing.5.
Deirdre A. Hill Jennifer S. Haas Robert Wellman Rebecca A. Hubbard Christoph I. Lee Jennifer Alford-Teaster Karen J. Wernli Louise M. Henderson Natasha K. Stout Anna N. A. Tosteson Karla Kerlikowske Tracy Onega 《Journal of general internal medicine》2018,33(3):275-283
Background
Breast cancer screening with magnetic resonance imaging (MRI) may be a useful adjunct to screening mammography in high-risk women, but MRI uptake may be increasing rapidly among low- and average-risk women for whom benefits are unestablished. Comparatively little is known about use of screening MRI in community practice.Objective
To assess relative utilization of MRI among women who do and do not meet professional society guidelines for supplemental screening, and describe utilization according to breast cancer risk indications.Design
Prospective cohort study conducted between 2007 and 2014.Participants
In five regional imaging registries participating in the Breast Cancer Surveillance Consortium (BCSC), 348,955 women received a screening mammogram, of whom 1499 underwent screening MRI.Main measures
Lifetime breast cancer risk (< 20% or ≥ 20%) estimated by family history of two or more first-degree relatives, and Gail model risk estimates. Breast Imaging Reporting and Data System breast density and benign breast diseases also were assessed. Relative risks (RR) for undergoing screening MRI were estimated using Poisson regression.Key results
Among women with < 20% lifetime risk, which does not meet professional guidelines for supplementary MRI screening, and no first-degree breast cancer family history, screening MRI utilization was elevated among those with extremely dense breasts [RR 2.2; 95% confidence interval (CI) 1.7–2.8] relative to those with scattered fibroglandular densities and among women with atypia (RR 7.4; 95% CI 3.9–14.3.) or lobular carcinoma in situ (RR 33.1; 95% CI 18.0–60.9) relative to women with non-proliferative disease. Approximately 82.9% (95% CI 80.8%–84.7%) of screening MRIs occurred among women who did not meet professional guidelines and 35.5% (95% CI 33.1–37.9%) among women considered at low-to-average breast cancer risk.Conclusion
Utilization of screening MRI in community settings is not consistent with current professional guidelines and the goal of delivery of high-value care.6.
David Itskoviz Zohar Levi Doron Boltin Alex Vilkin Yifat Snir Rachel Gingold-Belfer Yaron Niv Iris Dotan Ram Dickman 《Digestive diseases and sciences》2018,63(6):1513-1517
Background
Barrett’s esophagus (BE) is a known complication of gastroesophageal reflux disease. In a previous study, we described a high prevalence of intestinal metaplasia (IM) in patients with an irregular Z line. However, the clinical importance of this finding is unclear.Goals
To evaluate the long-term development of BE and relevant complications in patients diagnosed with an irregular Z line, with or without IM, on routine esophago-gastro-duodenoscopy (EGD).Methods
In our previously described cohort, 166 out of 2000 consecutive patients were diagnosed with an incidental irregular Z line. Of those with irregular Z line, 43% had IM. In this continuation study, patients’ status was reassessed after a median follow-up of 70 months. Patients were divided into two groups: Patients with IM (IM-positive group) and without IM (IM-negative group). The incidence of long-term development of BE, dysplasia, and esophageal adenocarcinoma were compared between groups.Results
At least one follow-up EGD was performed in 102 (61%) patients with an irregular Z line. Endoscopic evidence of BE was found in eight IM-positive patients (8/50 [16%]) and in one IM-negative patient (1/52 [1.9%]). Two (4%) IM-positive patients developed BE with low-grade dysplasia. None of the patients developed high-grade dysplasia, or esophageal adenocarcinoma.Conclusions
Patients with irregular Z line do not develop major BE complication in more than 5 years of follow-up.7.
E. M. van der Schans T. J. C. Paulides N. A. Wijffels E. C. J. Consten 《Techniques in coloproctology》2018,22(8):589-596
Background
Rectal prolapse—both external rectal prolapse and internal rectal prolapse—is a disabling condition. In view of the overwhelming number of surgical procedures described for the treatment of rectal prolapse, a comprehensive update concerning the diagnostic and therapeutic pathway for this condition is required to draw recommendations for clinical practice. This initiative was commissioned by the Dutch Association for Surgery (Nederlandse Vereniging voor Heelkunde) as a multidisciplinary collaboration.Methods
Nine questions outlining the diagnostic approach, conservative and surgical management of rectal prolapse were selected. A systematic literature search for evidence was then conducted in the Medline and Embase databases.Results
Recommendations included diagnostic approach, methods to assess complaints of fecal incontinence and/or obstructive defecation and treatment options, both conservative and surgical. A level of evidence was assigned to each statement following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system.Conclusions
These guidelines for clinical practice are useful in the diagnosis and treatment of rectal prolapse. There are many statements requiring a higher level of evidence due to a lack of studies.8.
Emily F. Midura Andrew D. Jung Meghan C. Daly Dennis J. Hanseman Bradley R. Davis Shimul A. Shah Ian M. Paquette 《Digestive diseases and sciences》2017,62(8):1906-1912
Background
Neoadjuvant chemoradiation reduces local recurrence in locally advanced rectal cancer, and adherence to national and societal recommendations remains unknown.Objective
To determine variability in guideline adherence in rectal cancer treatment and investigate whether hospital volume correlated with variability seen.Design
We performed a retrospective analysis using the National Cancer Database rectal cancer participant user files from 2005 to 2010. Stage-specific predictors of neoadjuvant chemotherapy and radiation use were determined, and variation in use across hospitals analyzed. Hospitals were ranked based on likelihood of preoperative therapy use by stage, and observed-to-expected ratios for neoadjuvant therapy use calculated. Hospital outliers were identified, and their center characteristics compared.Results
A total of 23,488 patients were identified at 1183 hospitals. There was substantial variability in the use of neoadjuvant chemoradiation across hospitals. Patients managed outside clinical guidelines for both stage 1 and stage 3 disease tended to receive treatment at lower-volume, community cancer centers.Conclusions
There is substantial variability in adherence to national guidelines in the use of neoadjuvant chemoradiation for rectal cancer across all stages. Both hospital volume and center type are associated with over-treatment of early-stage tumors and under-treatment of more invasive tumors. These findings identify a clear need for national quality improvement efforts in the treatment of rectal cancer.9.
Background
Patients with cancer and recommendations for aftercare are increasing worldwide.Objectives
Presentation of the current follow-up guidelines of selected gastrointestinal tumors.Materials and methods
The current German S3 guidelines for colorectal cancer, pancreatic cancer, hepatocellular carcinoma, and gastric cancer are analyzed.Results
The S3 guidelines for colorectal cancer and hepatocellular carcinoma favor structured aftercare. For a period of 2–5 years, a combination of case history, physical examination, imaging, endoscopy, and determination of tumor markers is recommended. Advocacy for structured aftercare for pancreatic or gastric cancer must be decided individually. In general, the follow-up time and interval should be adjusted to the complaints of the patient, regardless of the tumor type.Conclusions
Structured aftercare makes sense and is already part in the monitoring of selected gastrointestinal tumors.10.
Ethan A. Halm Elisabeth F. Beaber Dale McLerran Jessica Chubak Douglas A. Corley Carolyn M. Rutter Chyke A. Doubeni Jennifer S. Haas Bijal A. Balasubramanian 《Journal of general internal medicine》2016,31(10):1190-1197
Background
Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.Objective
To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).Design
Population-based cohort study.Participants
A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Measures
Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.Results
Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).Conclusions
Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.11.
BACKGROUND
Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population.OBJECTIVE
We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers.DESIGN
Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data.PATIENTS
Cohort of patients who smoke and who gained Medicaid coverage in 2008–2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n?=?4140 matched pairs; 8280 patients).INTERVENTION
Gaining Medicaid after being uninsured for ≥ 6 months.MAIN MEASURES
‘Quit’ smoking status (baseline smoking status was ‘current every day’ or ‘some day’ and status change to ‘former smoker’ at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period.KEY RESULTS
The newly insured had 40 % increased odds of quitting smoking (aOR?=?1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR?=?2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR?=?2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts.CONCLUSIONS
Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation.12.
Aim
The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA.Methods
All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate.Results
Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort.Conclusion
The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations.What does this paper add to the literature?
This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the Eastern population, RIPASA demonstrated a high-sensitivity, specificity, positive predictive value and diagnostic accuracy in our cohort and was more accurate than the commonly used Alvarado score.13.
Joy Chang Kenneth Fasanella Jennifer Chennat Jon Davison Kevin McGrath 《Esophagus》2016,13(2):151-155
Background
With heightened awareness of the increasing rate of esophageal adenocarcinoma and success of endotherapy for Barrett’s neoplasia, our Barrett’s center has seen a rise in referrals for evaluation and management of Barrett’s esophagus. We sought to compare the prevalence of neoplasia in patients with short- (<3 cm) versus long-segment Barrett’s esophagus (≥3 cm) referred to our Barrett’s center.Methods
We performed a retrospective analysis of endoscopic procedures and pathology reports in adult patients (age >18) referred to our Barrett’s center over a 6-year period. Neoplasia was defined as low-grade dysplasia, high-grade dysplasia and superficial esophageal adenocarcinoma. Outcome measures included the prevalence of neoplasia in short- vs long-segment Barrett’s esophagus.Results
Four-hundred and eighty-five patients (74 % male) were identified; 51 % had short-segment and 49 % had long-segment Barrett’s esophagus. The prevalence of neoplasia in short- vs long-segment Barrett’s esophagus was 33.6 vs 59.1 % (low-grade dysplasia 8.0 vs 14.5 %, high-grade dysplasia 12.8 vs 24.7 %, esophageal adenocarcinoma 12.8 vs 20.0 %). Long-segment Barrett’s esophagus was associated with 2.55-fold increase in odds of neoplasia relative to the short-segment group (OR 2.55, p < 0.001, CI 1.73–3.76).Conclusion
Neoplasia was more prevalent in patients with long-segment Barrett’s. Surprisingly, 23.4 % of patients with an “irregular Z line” harbored advanced neoplasia (high grade dysplasia or esophageal adenocarcinoma) in our biased referral population. This suggests that patients with an “irregular Z line” should be biopsied and, if intestinal metaplasia is detected, surveyed per established Barrett’s esophagus guidelines.14.
Aymer Al-Mutairi Ashley N. D. Meyer Eric J. Thomas Jason M. Etchegaray Kevin M. Roy Maria Caridad Davalos Shazia Sheikh Hardeep Singh 《Journal of general internal medicine》2016,31(6):602-608
IMPORTANCE
Diagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement.OBJECTIVES
We aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews.DESIGN
We gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (n?=?389), with and without previously identified diagnostic errors (n?=?129 and n?=?260, respectively).RESULTS
The final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient–provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84 %, sensitivity of 71 %, specificity of 90 %, negative predictive value of 86 %, and positive predictive value of 78 %. All 11 items correlated significantly with the instrument’s error outcome question (all p values?≤?0.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach’s alpha coefficients 0.93, 0.92, and 0.38, respectively).CONCLUSIONS
The Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.15.
Background
Gallstones are present in approximately 10–20?% of the German population. Up to one fourth of them will develop symptoms or complications during their lifetime.Objective
Based on recent guidelines, this paper reviews the evidence-based management of patients with gallstone disease.Materials and methods
Most relevant recommendations of the updated S3 guidelines on the diagnosis and treatment of gallstone disease are provided. Developments are depicted in relation to the 2007 version of these guidelines. Complementary recommendations of the S2k guidelines on quality requirements for gastrointestinal endoscopy and of the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) guidelines on interventional ultrasound in gallstone disease are referred to.Results
Based on recent scientific evidence, the guideline recommendations for diagnosis and treatment of patients with gallstone disease are presented. Requirements are rising for early surgical treatment of patients with acute cholecystitis (24 h), the timely management of patients with acute cholangitis and biliary pancreatitis (depending on severity) and on the sequential treatment of patients with simultaneous gallbladder and common bile duct stones (laparascopic cholecystectomy within 72 h after endoscopic bile duct clearance).Conclusions
Up-to-date guideline-based management of patients with gallstone disease is an interdisciplinary task and requires comprehensive management concepts. A guideline-based algorithm is introduced.16.
Emily C. Alper Ivan K. Ip Patricia Balthazar Gregory Piazza Samuel Z. Goldhaber Carol B. Benson Ronilda Lacson Ramin Khorasani 《Journal of general internal medicine》2018,33(1):21-25
Background
The Wells score for deep venous thrombosis (DVT) has a high failure rate and low efficiency among inpatients.Objective
To create and validate an inpatient-specific risk stratification model to help assess pre-test probability of DVT in hospitalized patients.Design
Prospective cohort study of hospitalized patients undergoing lower-extremity ultrasonography studies (LEUS) for suspected DVT. Demographics, physical findings, medical history, medications, hospitalization, and laboratory and imaging results were collected. Samples were divided into model derivation (patients undergoing LEUS 11/1/2012–12/31/2013) and validation cohorts (LEUS 1/1/2014–5/31/2015). A DVT prediction rule was derived using the recursive partitioning algorithm (decision tree-type approach) and was then validated.Participants
Adult inpatients undergoing LEUS for suspected DVT from November 2012 to May 2015, excluding those with DVT in the prior 3 months, at a 793-bed, urban academic quaternary-care hospital with ~50,000 admissions annually.Main Measures
The primary outcome was the presence of proximal DVT, and the secondary outcome was the presence of any DVT (proximal or distal). Model sensitivity and specificity for predicting DVT were calculated.Key Results
Recursive partitioning yielded four variables (previous DVT, active cancer, hospitalization ≥ 6 days, age ≥ 46 years) that optimized the prediction of proximal DVT and yield in the derivation cohort. From this decision tree, we stratified a scoring system using the validation cohort, categorizing patients into low- and high-risk groups. The incidence rates of proximal DVT were 2.9% and 12.0%, and of any DVT were 5.2% and 21.0%, for the low- and high-risk groups, respectively. The AUC for the discriminatory accuracy of the Center for Evidence-Based Imaging (CEBI) score for risk of proximal DVT identified on LEUS was 0.73. Model sensitivity was 98.1% for proximal and 98.1% for any DVT.Conclusions
In hospitalized adults, specific factors can help clinicians predict risk of DVT, identifying those with low pre-test probability, in whom ultrasonography can be safely avoided.17.
Michael Usher Nishant Sahni Dana Herrigel Gyorgy Simon Genevieve B. Melton Anne Joseph Andrew Olson 《Journal of general internal medicine》2018,33(9):1447-1453
Background
Studying diagnostic error at the population level requires an understanding of how diagnoses change over time.Objective
To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.Design
Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.Participants
Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.Main Measures
We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.Key Results
Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10–1.11, p?<?0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p?<?0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89–0.99, p?<?0.001).Conclusions
Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.18.
Purpose of Review
In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.Recent Findings
While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment.Summary
New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.19.
Giovanni B. Gaeta Massimo Puoti Nicola Coppola Teresa Santantonio Raffaele Bruno Antonio Chirianni Massimo Galli 《Infection》2018,46(2):183-188
Aim
This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).Methods
This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.Results
Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.Conclusions
Early treatment with DAA should be offered when available.20.