Choosing wisely in the ED: The diagnostic cascade of needless medical testing in a two-level study

BackgroundThe diagnostic cascade in the emergency department (ED) has not been fully elucidated.AimTo inspect whether the usage of consulting medicine and imaging contributes to hospital outcomes. We also propose a theoretical model for better understanding the diagnostic cascade of needless medical testing.MethodsA two-level study was conducted. The first local phase was a retrospective archive study that was conducted between 2014 and 2017 in a tertiary hospital. We extracted the number of requested imaging and consultations for each patient, and main time lags were calculated. The second-phase (January–April 2018) was conducted on a national level. We examined 22 hospitals with the emphasis on five hospital outcomes: recurrent ED visits (within 24 h), median waiting time at the ED, rate of early discharge at the same day and day after and percentage of patients spending >4 h in the ED.ResultsA 5% upsurge in CT scans was observed (p = .032), and a significant increase was found in the number of consultations (14%, p = .002). On a national level, a linear regression model found that the proportion of patients discharged from the hospital on the same day and on the day after and the proportion of patients staying in the ED > 4 h predict ED recurrence visits within 24 h (p = .025; R² = 46.3%).ConclusionsUpsurge in resource usage in the ED leads to a diagnostic cascade of health consumption. Further study is necessary to examine the proposed model in a global scale.     

Bilateral acute iris transillumination following a fumigation therapy: a village-based traditional method for the treatment of ophthalmomyiasis

Bilateral acute iris transillumination (BAIT) is a relatively new clinical entity characterized by bilateral acute loss of iris pigment epithelium, iris transillumination, pigment dispersion in the anterior chamber and atonic pupilla. We report herein a 50-year-old female who presented with bilateral ocular pain, severe photophobia and red eyes. One month ago, a fly hit her eye, and she instantly complained of a discomfort and sensation of a foreign body in both eyes. She used a fumigation therapy, a traditional method for the treatment of ophthalmomyiasis. During follow-up examinations, intraocular pressures increased over 40?mmHg bilaterally despite maximal medical therapy, which necessitated trabeculectomy surgery with mitomycin. This is a typical BAIT case with no antecedent fluoroquinolone use or viral disease, but a fumigation therapy. There might be a possible relationship between BAIT and traditional fumigation therapy or this association might be coincidental, both of which need further evaluation.     

Angiogenic factors,bladder neuroplasticity and interstitial cystitis—new pathobiological insights

Vascular endothelial growth factor (VEGF) is essential for normal embryonic development, and maintenance of adult vascular function. Originally described as a vascular permeability factor, VEGF alters tight cell junctions and contributes to maintenance of bladder permeability. VEGF and its receptors are not only expressed in bladder blood vessels but also in apical cells and intramural ganglia. VEGF receptors are fundamentally altered by inflammation and bladder diseases such as interstitial cystitis (IC). Experimental results indicate that VEGF exerts direct effects on bladder nerve density and function. Regardless of the etiology or initiating cause for IC, it is hypothesized that the urinary bladder responds to injury by increasing the production of VEGF that acts initially as a survival mechanism. However, VEGF also has the capacity to increase vascular permeability leading to glomerulations, edema, and inflammation. Moreover, due to elevated numbers of VEGF receptors in the urothelium, the increased levels of VEGF further increase bladder permeability and establish a vicioCus cycle of disease pathophysiology.     

Characteristics of the Turkish isolates of Francisella tularensis

In this study, cultures of patients with tularemia were evaluated, and antimicrobial susceptibilities of two Francisella tularensis strains were tested by disk diffusion and E-test methods. A high-resolution multiple-locus variable-number tandem repeat analysis (MLVA) comprising six variable-number tandem repeat loci was applied to elucidate the genetic relatedness among Turkish and Bulgarian isolates which were isolated in a recent outbreak. The patients were diagnosed in two outbreaks in two cities of Turkey in 2005 and 2006. A total of 16 samples from 12 patients were cultured, and PCR tests were carried out on 15 samples that were positive in five lymph node aspirates and two soft tissue aspirates. F. tularensis was isolated from the lymph nodes of two patients. Aminoglycosides, quinolones, chloramphenicole, tetracyclines, nitrofurantoin, and rifampicin inhibited growth of the isolates. The Turkish isolates appeared to share a common MLVA pattern with one of the four Bulgarian outbreak genotypes.     

Loss of programmed cell death 10 activates tumor cells and leads to temozolomide-resistance in glioblastoma

Journal of Neuro-Oncology - Glioblastoma (GBM) is one of the most aggressive and incurable primary brain tumors. Identification of novel therapeutic targets is an urgent priority. Programmed cell...