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PubMedDate not supplied

[New approaches to the measurement of clinical competence].

A new phase in the development of an instrument designed for the measurement of clinical competence is presented. The instrument (exam type) was previously validated; we report its use in three generations of students of a specialization course in internal medicine: those recently admitted to the course (group I); those finishing their first training year (group II) and those finishing the second year (group III). In the exam 304 out of the 600 questions included were classified as "experimental" (dealing with knowledge in internal medicine) and the remaining 296 questions corresponded to "control" questions (dealing with knowledge in other specialties). The variables considered in the exam were: 1) global result; 2) usage of diagnostic indicators; 3) omission of necessary procedures without a iatrogenic effect; 4) commission of unnecessary procedures without a iatrogenic effect; 5) omission of necessary procedures with resulting iatrogenic consequences; 6) commission of unnecessary procedures with resulting iatrogenic consequences; 7) global omission (variables 3 and 5); 8) global commission (variables 4 and 6); 9) global iatrogenesis (variables 5 and 6); 10) knowledge in nosology. Scores obtained by the three groups on the experimental questions differed in accordance with the respective time of clinical experience (group I obtained the lowest scores, group II showed intermediate scores, and group III showed the highest scores). Analysis of variance was significant (p less than 0.05) in variables 1, 2, 6, 8 and 9. The scores obtained by the three groups on the control questions were similar. In conclusion, we believe that this instrument is capable of detecting learning dependent on the time of clinical experience.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗
PubMed2005

Missed diagnosis of schistosomiasis leading to unnecessary surgical procedures in Jos University Teaching Hospital.

Twelve cases of radical surgery were carried out on patients with schistosoma granuloma mistaken for malignant lesions. Such radical procedures could have been averted if pre-operative biopsies were done. Therefore, there is a need for clinicians practising in schistosoma endemic areas to routinely carry out pre-operative biopsy to minimize missed diagnosis of schistosomiasis.

Adolescent↗
PubMed2004

Measurement of fractional flow reserve in patients with multi-vessel coronary artery disease and borderline lesions prevents unnecessary revascularisation procedures.

BACKGROUND: Patients with multi-vessel coronary artery disease (CAD) are selected for percutaneous coronary interventions (PCI) or surgical revascularisation. The appropriateness of "ad hoc" PCI of borderline lesions (<70% of lumen diameter) in patients with a multi-vessel CAD has not been proven. However, delayed PCI of another lesion and gaining additional information from non-invasive tests is not a widely accepted strategy. When left anterior descending (LAD) coronary artery is one of the affected vessels, selection for surgical revascularisation is most likely. AIM: To assess long-term outcome in patients with multi-vessel CAD and borderline lesions, including LAD, in whom fractional flow reserve (FFR) in all affected vessels was measured and used for selection for PCI or conservative treatment. METHODS: The study group consisted of 16 patients with stable angina (11 males, mean age 60+/-9 years) with 34 lesions localised in the main epicardial coronary arteries [LAD / left main (LM) / right coronary artery (RCA) / intermediate branch (IB) / circumflex artery (Cx) - 15/1/5/5/8] of which at least two were borderline stenoses. Each lesion underwent FFR measurement. "Ad hoc" PCI was performed when FFR was <0.75, and conservative therapy was instituted when FFR was >0.75. RESULTS: Of 34 lesions, in 8 (23%) the FFR value was <0.75 and these lesions were treated with PCI (LAD/IB/Cx - 3/2/3). In the remaining 26 (77%) lesions, FFR was >0.75 and conservative therapy was instituted. During the mean follow-up of 15+/-6 months (range 6-28 months, median 15 months) in 8 of 9 conservatively treated patients no aggravation of anginal symptoms nor other coronary events were observed. One patient developed acute myocardial infarction due to thrombus occluding a borderline LAD lesion. Of 8 lesions treated with PCI (baseline FFR = 0.63+/-0.10 vs post-PCI FFR = 0.92+/-0.08, p=0.0002), in one case an in-stent restenosis in LAD occurred 9 months after PCI. Of a total of 26 lesions which were conservatively treated (mean FFR 0.91+/-0.05), in 2 (7.7%) the progression of CAD was noted. CONCLUSIONS: In patients with multi-vessel CAD and borderline lesions, FFR measurement identifies those, who can be treated conservatively with a good long-term outcome, and prevents unnecessary PCI.

Aged↗
PubMed2000

Improving the quality of care through routine teleradiology consultation.

RATIONALE AND OBJECTIVES: The hypotheses of this study were as follows: (a) University subspecialty radiologists can provide consultations effectively to general radiologists as part of routine clinical operations; (b) these consultations will improve the quality of the final radiologic report; and (c) the consultations will improve the care process and may save money, as well. MATERIALS AND METHODS: For 2,012 consecutive computed tomographic or magnetic resonance (MR) imaging studies, the initial interpretations provided by radiology generalists were subsequently reviewed by specialists, with a final consensus report available. "Truth" was established by final consensus reports. To control for potential bias, 150 adult MR imaging and 250 pediatric radiologic studies were interpreted initially by specialists and then by generalists. Again, truth was established by final consensus reports. RESULTS: There was disagreement between generalist and specialist radiologist interpretations in 427 (21.2%) of the cases reviewed. These disagreements were stratified further by independent specialists, who graded them as important, very important, or unimportant. Differences were considered important or very important in 99% of the cases reviewed. CONCLUSION: Consultations by subspecialty radiologists improved the quality of the radiology reports studied and, at least in some cases, improved the process of care by eliminating unnecessary procedures or suggesting more specific follow-up examinations. The consultation services can be provided cost-effectively from the payer's perspective and may save additional costs when unnecessary procedures can be eliminated.

Humans↗
PubMed2002

Parapharyngeal space tumours: an 18 year review.

Parapharyngeal space tumours account for only 0.5 per cent of all head and neck tumours. Due to their inherent location, they present with varied non-specific signs and symptoms, resulting in a delay in diagnosis and unnecessary procedures, such as a 'tonsillectomy' or 'incision and drainage' of a 'quinsy'. Thirty-one patients, operated on over an 18-year period (1981 to 1998), in the Department of Otolaryngology, Singapore General Hospital, are presented. Their ages ranged from 21 to 86 years, with a mean of 52 years, with equal sex distribution. The commonest aetiology was a deep lobe of parotid tumour (44 per cent), followed by neurilemmomas (18 per cent), there was only one paraganglioma. The transcervical and transparotid approaches were the commonest used. The mean surgical time was three hours, mean hospital stay was 5.3 days and post-operative complications were minimal. The average follow-up time was 5.6 years. Although parapharyngeal space tumours are uncommon, recognizing them would enable the correct sequence of investigations, instead of unnecessary procedures resulting in an increased morbidity for the patient.

Adult↗
PubMed1991

Unnecessary and ecological cost of hospital infection.

Hospital infection control can be accomplished with less pollution to the environment, nevertheless retaining the same standard of hygiene. Waste reduction also means cost reduction. Some examples of avoidable ecological costs are unnecessary nursing techniques, unnecessary gowning and disinfection procedures, unnecessary packing material and disposables.

Communicable Disease Control↗
PubMed1994

Defining unnecessary disinfection procedures for single-dose and multiple-dose vials.

BACKGROUND: Recommendations in the literature conflict on the necessity of disinfecting single-use vials prior to aspiration of fluid. Interventions to disinfect the stopper surface on multiple-dose vials vary considerably. OBJECTIVES: To determine the necessity of alcohol disinfection of the stopper on single-dose vials and to compare povidone-iodine and alcohol versus alcohol-only disinfection of the stopper prior to each needle penetration on multiple-dose vials. METHODS: The rubber stopper surfaces of 100 single-dose vials were cultured for the presence of bacteria. To determine the efficacy of two procedures for disinfection of multiple-dose vials, 87 stopper surfaces routinely disinfected with both povidone-iodine and alcohol were cultured for bacteria. After a change in practice, 100 multiple-dose vials routinely disinfected with alcohol only were cultured for the presence of bacteria. RESULTS: Of the cultures done on single-dose vial stoppers, 99% were sterile. A comparison of the two disinfection techniques for multiple-dose vials revealed that 83 (95%) of the 87 vials prepped with both povidone-iodine and alcohol were sterile, compared with all stoppers disinfected with alcohol only. CONCLUSIONS: This study shows the lack of necessity of any disinfection procedure on the rubber stopper of single-dose vials and the efficacy of alcohol only for disinfecting the stopper of multiple-dose vials.

1-Propanol↗
PubMed2001

Negative knee arthroscopy: Is it really negative?

PURPOSE: To evaluate the outcome of patients in whom knee arthroscopy proved to be normal. TYPE OF STUDY: Retrospective study. METHODS: Knee arthroscopy is probably the most common procedure performed in orthopaedic practice. A number of patients who undergo this procedure do not have any abnormality detected. Is negative arthroscopy really such an unnecessary procedure? Hospital records of patients who had undergone knee arthroscopy were retrospectively studied and all patients with a normal knee arthroscopy were selected. Fifty-three patients (55 knees) with a normal arthroscopy were included into the study. Patients were then interviewed either by telephone or questionnaire to ascertain current symptoms, job changes, and patient perception of the procedure. RESULTS: The mean follow-up was 43 months. Fifty percent of the patients had a history of injury, and the preoperative diagnosis was thought to be a meniscal lesion or a rupture of the anterior cruciate ligament in 38% of patients. Sixty-eight percent of the patients felt that they were better and there were no complications. The incidence of all symptoms were significantly reduced after arthroscopy. CONCLUSIONS: A significant number of patients felt that they were better after the knee arthroscopy. The reason for this is not entirely clear. It may well be attributable to a placebo effect, the fact that patients now know that there is no abnormality and learn to live with the symptoms, or there may be an additional benefit of the procedure itself.

Adolescent↗
PubMed2001

Physician interpretation of electrocardiographic artifact that mimics ventricular tachycardia.

BACKGROUND: Patients who are misdiagnosed with ventricular tachycardia because of electrocardiographic artifact may be subjected to unnecessary procedures. The purpose of this study was to determine how often electrocardiographic artifact is misdiagnosed as ventricular tachycardia. METHODS: Physicians (n = 766) were surveyed with a case simulation that included a two-lead electrocardiographic monitor tracing of artifact simulating a wide-complex tachycardia. RESULTS: The rhythm strip was not recognized as artifact by 52 of the 55 internists (94%), 128 of the 221 cardiologists (58%), and 186 of the 490 electrophysiologists (38%). One hundred fifty-six of the 181 electrophysiologists (88%), 67 of the 126 cardiologists (53%), and 14 of the 15 internists (31%) who misdiagnosed the rhythm as ventricular tachycardia recommended an invasive procedure for further evaluation or therapy. CONCLUSIONS: This physician survey suggests that electrocardiographic artifact that mimics ventricular tachycardia may frequently result in patients being subjected to unnecessary invasive cardiac procedures. Physicians should include artifact in their differential diagnosis of wide complex tachycardias to minimize unneeded procedures.

Artifacts↗
PubMed1998

Prospective study of the accuracy of the surgeon's diagnosis in 2000 excised skin tumors.

Expeditious yet efficacious removal of skin tumors is a common responsibility for the plastic surgeon. The need to minimize potential risks for mortality or morbidity from undue or excessive surgical resections and to control costs by avoiding unnecessary procedures behooves us to make a precise clinical diagnosis preceding any decision even for such "minor" surgery. Just how accurate these decisions can be expected to be for a typical surgical practice was scrutinized by means of this prospective 4-year study involving the resection of 2058 skin lesions. Each lesion was initially assigned a clinical diagnosis after a brief gross examination and then compared with the pathology report, which was always considered to be the correct answer. Within these parameters, only 65 percent of all tumors were identified correctly preoperatively. Two-thirds of all lesions were benign. Three-quarters of benign lesions were as assumed, and 92 percent of all presumed benign lesions were benign even if incorrectly identified initially, whereas fortunately only 3 percent proved to be malignant. On the other hand, only three-fifths of malignant lesions were identified correctly clinically, yet only 11 percent were benign, implying that most such lesions properly deserved excision anyway. Therefore, approximately 90 percent of all lesions whether benign or malignant were removed appropriately without compromising the patient, but to expect a clinical acumen of 100 percent in this setting may not be realistic. The accuracy of the surgeon in identifying lesions as probably benign was certainly high enough that cost-containment mechanisms designed to deny authorization for their removal probably would be justifiable and difficult to appeal. Any suspicious or equivocal lesions still will require mandatory intervention despite such constraints, because often only histologic examination will allow a definitive diagnosis.

Basal Cell Carcinoma↗
PubMed2000

False-negative mammograms. Medical, legal, and risk management implications.

From a strictly biologic perspective, delay in diagnosis of breast cancer is axiomatic. The number of cell divisions that must occur before detection is possible by either clinical or mammographic methods means that a finite time has occurred in which the outcome for any given case may have already been determined. That early detection and diagnosis of breast cancer lead to improved survival may be intuitive, but clinical trials have been necessary to validate the concept. Delay in diagnosis is unavoidable but the period of delay may be lessened in many cases, prompting earlier intervention and impacting outcomes. Mammography is an important vehicle for such earlier intervention and the issue of the false-negative mammogram is of concern to the radiology community, the lay community, and the courts. Mammographic interpretation has not yet approached a sufficiently standardized benchmark. Detection and diagnosis are dependent on a series of factors that need to be integrated to achieve the dual goals of timely intervention for bonafide purposes and reduction of unnecessary procedures and interventions. Some of the reasons for delay in diagnosis are unavoidable, beginning with the absence of clinical or imaging features of malignancy and extending to limitations of sufficiently specific features to prompt intervention. On the other hand, other reasons are avoidable and attention to many of these causes should lessen the incidence of such delay. Regardless of the reason, those women who feel that their breast cancer should have been diagnosed at an earlier time may consider subjecting their mammographic studies to independent reviews. At such a point, the precise reasons for delay may be better analyzed, all in an attempt to provide an adequate reconciliation of what has come to be known as the false-negative mammogram.

Benchmarking↗
PubMed1999

[Contralateral transinguinal laparoscopy in unilateral inguinal hernia].

BACKGROUND: Indication for surgical exploration of the contralateral groin during unilateral herniorraphy in children is the subject of a worldwide debate. Routine exploration based on the likelihood of a patent processus vaginalis (PV) according to age, gender or side to some extent leads to unnecessary procedures, while routine abstention may leave a peritoneal sac, likely to later induce a symptomatic hernia in about 10% of cases. METHODS AND PATIENTS: One hundred and twenty-five children aged from 1 month to 15 years underwent transinguinal laparoscopic assessment of the contralateral groin, using a 3 mm trocar and a 70 degrees telescope gently introduced through the exposed PV. Surgical exploration was performed only in those patients who exhibited a patent PV, and in patients where the groin was poorly visualized due to technical problems. RESULTS: Regardless of age, contralateral surgery was not considered in 88 (70%) of the 125 children. Among the 37 patients that were operated upon, eight had a negative exploration due to an erroneous endoscopic evaluation. Surgery was avoided in 35 (56%) of the 62 infants aged less than 2 years, including nine of the 13 prematures who were previously routinely operated upon. Conversely, in the 63 older patients who were readily spared from surgical exploration, the videoscopic evaluation allowed appropriate selection for contralateral surgery in six. CONCLUSION: A routine policy, either of surgery or observation, is no longer indicated as a quick, safe and cost-effective method is available to detect a patent PV. The transinguinal laparoscopy is safe and could be easily performed by surgeons already skilled in pediatric herniorraphy. Therefore, the videoscopic transinguinal contralateral evaluation is worth being promoted to ensure an appropriate surgery tailored to the anatomical features.

Adolescent↗
PubMed2002

Clinical impact of endoscopic ultrasonography at a county hospital.

BACKGROUND AND STUDY AIMS: Although endoscopic ultrasonography (EUS) is a well-described examination method, there have been few reports concerning its clinical impact. The aim of this study was to describe EUS as it is performed at a county hospital, with an emphasis on the indications and clinical outcome. PATIENTS AND METHODS: Patients examined using EUS between December 1997 and November 2000 were recorded prospectively. Follow-up was conducted by examining each patient's medical records at least 3 months after the investigation. The EUS findings were compared with the patient's final diagnosis, and the decisions made by the referring department on the basis of each investigation were recorded. RESULTS: A total of 344 EUS procedures were performed. In the third year, the distribution of patients relative to the various referral diagnoses was: 78 with suspected benign pancreaticobiliary disease, 33 for staging of known upper gastrointestinal tract malignancy, 15 with suspected mediastinal disease or for staging of lung cancer, 13 with suspected submucosal lesions, and five with unclassified disease. Follow-up was possible in 340 patients (99 %). Compared to the final diagnosis in each patient, the sensitivity, specificity, and accuracy rates of EUS were 86 %, 90 %, and 88 %, respectively. The EUS findings made more invasive procedures unnecessary in 199 patients (58 %). EUS led to a switch to less invasive procedures in 61 patients (18 %), and it had no influence on the further management strategy in 80 patients (24 %). CONCLUSIONS: EUS has a high level of accuracy and a substantial clinical impact when performed in an unselected population. The estimated numbers of investigations needed appear to justify setting up an EUS center at institutions with a catchment population of 350 000 inhabitants.

Adolescent↗
PubMed2003

Diaphragmatic duodenal atresia: laparoscopic repair.

Stenosis due to a diaphragm is a type of intrinsic duodenal obstruction in newborns and even in childhood, when obstruction is partial. We present a case of a 13-month-old girl with diaphragmatic stenosis associated with a dilated first and second duodenum. Surgical management consisted of a partial excision of the diaphragm after vertical incision of the anterior part of the second duodenum followed by a transverse suture. This diamond-shaped anastomosis was successfully carried out laparoscopically. No tapering of the duodenum was performed as some authors suggest in cases of megaduodenum. The rapid resumption of peristalsis and fewer adherences than expected after such a minimally invasive approach could make a more invasive procedure unnecessary. Only long-term follow-up and greater experience will show which procedure is most suitable.

Constriction, Pathologic↗
PubMed2002

Staging laparoscopy and its indications in pancreatic cancer patients.

BACKGROUND: Laparoscopy has become a popular and widespread surgical technique. An important goal in the treatment of patients with pancreatic cancer is to avoid any unnecessary procedure. Laparoscopy has been suggested as a routine tool for staging in order to prevent unnecessary laparotomies in these patients. METHODS: In this article we present our experience regarding the value of laparoscopic staging and review the literature on this topic. RESULTS AND CONCLUSION: A direct and conclusive comparison of the controversial literature is difficult because of different study designs. Inconsistent use of high-quality CT scans significantly affects the results. However, recent studies reveal that not more than 14% of the patients benefit from diagnostic laparoscopy when a state-of-the-art CT scan has been performed previously. Therefore, we conclude that routine diagnostic laparoscopy is not justified in all patients with pancreatic cancer. Rather, selective use is appropriate, especially in patients in whom ascites is an indirect sign of peritoneal metastases, or if liver metastases cannot be surely excluded preoperatively. This approach is cost-effective and limits diagnostic laparoscopy to a subgroup of patients in whom a laparotomy can be avoided.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2003

Selective performance of prophylactic omentopexy during laparoscopic implantation of peritoneal dialysis catheters.

Omental entrapment of the peritoneal dialysis catheter remains a common cause of flow dysfunction. Prophylactic omentectomy during catheter implantation is still followed with an incidence of flow obstruction as high as 10%. We describe indications and a technique for selective performance of omentopexy during laparoscopic catheter implantation that resulted in only a 0.7% obstruction rate in 153 consecutive patients as compared with a 12.8% rate in a preceding group of 78 consecutive patients. Laparoscopic omentopexy was performed during 9.2% of implant procedures and only when the omentum was found to extend to the retrovesical space. The procedure is simple, quick, and inexpensive to perform. Employing selective criteria for omentopexy eliminates the performance of unnecessary procedures. Actuarial analysis demonstrates that an operative strategy of selectively performing omentopexy for redundant omentum significantly improves catheter survival free of flow dysfunction (P < 0.0001).

Catheterization, Peripheral↗
PubMed1977

Thin needle cholangiography: experience with 50 patients.

Thin needle cholangiography (TNC) was performed in 50 patients with obstructive jaundice or jaundice of obscure origin. The purpose of this study was to assess the diagnostic accuracy and safety of this procedure. TNC was performed by the technique described by Redeker et al. using the Chiba needle (JAMA 231:386, 1975). Obstructed ducts were successfully demonstrated in 100% of cases (29/29). Non-obstructed ducts were opacified in 12/21 (57%). Overall success was 82% (41/50). Two septic complications occurred. It is concluded that 1) TNC is a highly reliable, easy to perform and safe procedure in the evaluation of the jaundiced patient; 2) Accurate demonstration of the biliary anatomy by TNC provided important information which often in (10/50 = 20%) led to a change in diagnosis, avoidance of unnecessary procedures, and shortening of hospitalization; 3) Failure to visualize patients with non-dilated biliary ducts occurred with advanced chronic liver disease or fatty liver.

Aged↗