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PubMed1996

[Iatrogenic complications and quality improvement in everyday medical practice].

There is a relationship between iatrogenic complications of medical procedures and the quality of medical services. The risk of iatrogenic complications or diseases occurring is growing over time for several reasons: patients under medical care grow older and sicker, diagnostic and therapeutic procedures are expanding at a fast pace, and complexity and uncertainty in daily care tends to grow. This development will continue unless we actively start to prevent iatrogenic complications. The frequency of iatrogenic illness was found to be between 4 and 36% of all patients treated in a hospital setting. The wide span is a result of different definitions of what is an iatrogenic complication. When an iatrogenic illness occurs we are obliged to look for "errors in the system"in order to eliminate them. In a hospital and practice environment the respective methods are different. By eliminating unnecessary procedures the risk of possible damage is diminished. Necessary procedures must be performed at the most skilled level. We describe and discuss two cases of iatrogenic complications and the benefits and disadvantages of guidelines. The creation of guidelines should be placed on a rational and scientific basis.

Adult↗

PubMed2006

Thoracoscopic application of a topical sealant for the management of persistent posttraumatic pneumothorax.

BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of blunt or penetrating chest trauma. Currently, most patients are managed with pleural chest tube(s) and suction drainage. Prolonged hospital stay and added cost of care are not uncommon. METHODS: Over a 2-year period, 13 patients with PPP, nonresponsive to conventional management, underwent video-assisted thoracoscopic surgery (VATS). As part of our protocol for PPP, routine preoperative computed tomography of the chest and bronchoscopy to determine the presence of associated injuries were performed in all of the patients. During the VATS procedure, all of the patients underwent drainage of any retained hemothorax, and a topical surgical sealant was applied to the source of the air leak as definitive treatment. RESULTS: A persistent pneumothorax with an air leak was identified in all 13 of the patients. There were 10 patients with blunt and 3 patients with penetrating injuries, respectively. The mean age for the patients was 34 years (range, 13 to 64 years). Parenchymal lacerations were identified in all of the patients ranging in size from 0.5 to 3 cm. After the VATS procedure and application of the surgical sealant, 11 patients had the chest tubes removed within 24 hours of the procedure. In the other two patients, the chest tubes were removed within 48 hours. There was no recurrence of the pneumothorax in any of these patients. The mean length of hospital stay before VATS and the application of the surgical sealant was 6 days (range, 2-14 days). CONCLUSION: Early VATS and the use of a topical sealant in patients with PPP is a safe and effective alternative to the conventional management with prolonged thoracostomy chest tubes or an open thoracostomy. This alternative management, when used early in the appropriate patient, will decrease the length of hospital stay, cost of care, and unnecessary procedures.

Administration, Topical↗

PubMed1994

HELLP syndrome: laboratory parameters and clinical course in four patients treated with plasma exchange.

We report our apheresis department's experience with four patients with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. The average age of the patients was 23.25 years (range 19-27). Three were in their second pregnancy while one was a primigravida. All had symptoms of pre-eclampsia prior to delivery. All experienced the syndrome postpartum. Plasma exchange was instituted an average of 3.25 days postpartum (range 1.08-7.33 days). All underwent plasmapheresis with fresh frozen plasma replacement. The average number of plasma exchange treatments was four (range 1-8). The first laboratory parameter to reach its peak/nadir was the aspartate aminotransferase (AST), followed by the lactate dehydrogenase (LDH) enzyme level, followed by the hemoglobin (HGB) level, and, finally, the platelet count (PLT). The AST was the first parameter to peak and the first to normalize. In the three cases in which more than one plasmapheresis procedure was performed, plasmapheresis was required for an average of 98 hours (range 39-206 hours) after a normal AST level was obtained in order to achieve a self-sustaining platelet count of > or = 100 x 10(9)/L. No additional exchanges were required to maintain the PLT once a PLT of over 100 x 10(9)/L was attained. The laboratory values normalized in the following order: AST, HGB, PLT, and LDH. Three patients were discharged anemic. One was discharged with a normal LDH level. By our experience, awaiting normal LDH levels as an indicator for cessation of plasma exchange therapy would mean subjecting the patients to many unnecessary procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2005

Reevaluating occult incontinence.

PURPOSE OF REVIEW: Occult incontinence is a controversial subject without significant exposure in the literature. Conventionally, it has been assumed to be a marker for increased risk of postoperative stress urinary incontinence (POSUI) after repair of pelvic organ prolapse. The controversy surrounds the performance of prophylactic incontinence procedures based on this assumption. Until 2004 no article in the English language had been published demonstrating an association between occult incontinence and increased risk of stress urinary incontinence after repair of severe pelvic organ prolapse in previously continent women. We will explore the evidence regarding occult incontinence, review the data on intervention trials, and address questions that remain. RECENT FINDINGS: The limited evidence suggests 11-22% of continent patients with severe pelvic organ prolapse will develop POSUI. New evidence suggests that patients with occult incontinence are at substantially more risk. Since anti-incontinence procedures in patients with occult incontinence reduces the incidence of POSUI (to 0-15%), there appears to be some benefit from screening and intervention. Most studies on the subject are small and limited by their design. Results differ regarding whether a negative stress test can be used to rule out the risk of POSUI. SUMMARY: Minimal existing evidence in the English language suggests that patients with occult incontinence are at increased risk of POSUI. Outcomes in occult incontinence patients undergoing repair of pelvic organ prolapse need systematic study. Until there is adequate solid evidence on the predictive values of our screening test, we cannot counsel patients regarding our ability to prevent POSUI or protect them from unnecessary procedures.

Female↗

PubMed2003

Are metal stents effective for palliation of malignant dysphagia and fistulas?

BACKGROUND: One of the available treatments for unresectable oesophagogastric malignancies is the insertion of metal stents. AIMS: We evaluated prospectively 147 patients suffering from malignant dysphagia and/or fistula, after inserting a self-expandable metal stent. PATIENTS AND METHODS: The study included 147 patients (87 males, mean age 73 years). Dysphagia before and after stent placement was scored. Patients were divided in two groups according to dysphagia grade: group A (grade 0, 1) and group B (grades 2, 3, 4). Three types of stents were used: the Ultraflex stent (covered and uncovered) and the Flamingo one (covered). The total number of self-expandable metal stents placed was 183. A total of 92 of them were inserted following the combined endoscopic and fluoroscopic approach (42 by injecting lipiodol), while 91 were placed under endoscopic control only. Early and late complications were evaluated. RESULTS: Mean dysphagia score in group A, 1 day and 1 month after the procedure, was slightly reduced from 0.8 to 0.5/0.6 (p=NS), respectively. However, there was a statistically significant improvement (p<0.001) of mean dysphagia score in group B, from 2.4 initially to 1.1/1.4. Early complications occurred in 37 cases, late ones in 51. According to severity, minor complications occurred in 24 patients, major in 42, while life-threatening ones in 22. Survival ranged from 1 to 611 days and 1-week mortality was 9%. Stent-related death occurred in six patients. CONCLUSIONS: All kinds of endoscopic methods used for stenting in the present study were easy to perform even on an out-patient basis. Insertion of self-expandable metal stents is effective in patients with dysphagia scores > or = 2. It might not clinically improve patients with dysphagia score <2, so selection of patients for stenting is essential to avoid unnecessary procedures. Moreover, their high cost, high complication rates and low overall survival may improve following better selection criteria.

Adenocarcinoma↗

PubMed2001

Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy: a case for the selective operative cholangiogram.

BACKGROUND: There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision. METHODS: The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained. RESULTS: Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC. CONCLUSIONS: The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.

Cholangiography↗

PubMed2004

Adjustable sutures in children using a modified technique.

PURPOSE: Adjustable-suture techniques are commonly used to decrease the reoperation rate in adults undergoing strabismus surgery, but they are infrequently used in children because of the difficulty of performing adjustments on a conscious child. The purpose of this study is to evaluate a new technique for using adjustable sutures in children, which makes the second stage of the procedure unnecessary if no adjustment is needed. METHODS: This was a retrospective study of children who underwent surgery for exotropia or esotropia. The technique used was a variation of the standard fornix-based adjustable suture with a separate slipknot. The pole sutures were buried within the sclera and tied; then the incision of the conjunctiva was closed to cover the adjustable sutures. The patients were then measured 4 to 6 hours after the initial surgery. The decision of whether to adjust was based on predetermined criteria. Those children not adjusted were discharged with no further manipulation needed because the conjunctiva was already closed. For those children who were adjusted, the adjustment was made with the patient under intravenous propofol sedation or laryngeal mask anesthesia. RESULTS: A total of 61 consecutive children ages 12 months to 14 years underwent surgery using this technique. Patients were followed-up after surgery for a minimum of 6 weeks (median 19.4). Fifty-four of the 61 patients (88%) were within 10 prism diopters (PD) of orthophoria on their final postoperative visit. Of the 22 patients who underwent an adjustment, 20 (91%) were within 10 PD of orthophoria at their final postoperative visit. The median follow-up was 19.4 weeks (range 6 to 45.9). CONCLUSIONS: This new adjustable-suture technique was associated with excellent short-term eye alignment. It is particularly suited for pediatric surgery because it eliminates the necessity of further manipulation of children who do not require adjustment.

Adolescent↗

PubMed2000

Genetic changes in solid tumors.

Although most solid tumors are treated surgically, determining the genetic changes present in the tumor of an individual patient is becoming increasingly important for managing the oncology patient. Our knowledge of the genetic alterations that characterize and predispose to solid tumors continues to expand. Concurrently, the advent of newer technologies such as DNA chips has the potential to enable a more rapid and comprehensive assessment of these changes. The ultimate goal of this new information and technology is to provide sensitive and specific tests that reduce unnecessary procedures and optimize therapy. This review addresses the utility of molecular testing in evaluating cancer. A review of the current technology and hereditary cancer syndromes is also presented.

Breast Neoplasms↗

PubMed1982

Cat-scratch disease simulating malignant lymphoma.

A six-year-old girl with induration, swelling and discoloration of the lower eyelid, a temporal mass, preauricular adenopathy and enlarged parotid gland, underwent biopsy, She was initially diagnosed as having a malignant disorder of histiocytic origin. All lesions resolved without therapy. Further evaluation revealed that the child had oculoglandular cat-scratch disease. Cat-scratch disease should be added to the list of nonmalignant disorders which may simulate a malignant neoplasm in its clinical and histologic appearance. Recognition of this fact is important in order to avoid erroneous diagnosis, unnecessary procedures and hazardous therapy.

Cat-Scratch Disease↗

PubMed2004

Anorectal cytology as a screening tool for anal squamous lesions: cytologic, anoscopic, and histologic correlation.

BACKGROUND: Anorectal cytology has been increasingly used as a screening method for anal squamous lesions, particularly in high-risk, homosexual, patients with human immunodeficiency virus infection. The diagnostic cytologic, anoscopic, and histologic criteria bear some resemblance to the criteria used in cervicovaginal samples with few differences. It is important to recognize these differences because they can lead to an erroneous diagnosis of dysplasia and unnecessary procedures. METHODS: Seventy-eight anorectal cytology specimens from 51 patients were reviewed blindly. Of the 51 patients, 33 were HIV positive. The cytology specimens consisted of 75 ThinPrep (Cytyc, Boxborough, MA) and 3 conventional Papanicolaou-stained smear specimens. The revised diagnosis was compared with the original diagnosis, corresponding histology specimens, and anoscopic results, when available. RESULTS: Six specimens were unsatisfactory for review. The revised diagnosis was negative in 15 patients, atypical squamous cells of undetermined significance in 3 patients, low-grade squamous intraepithelial lesions in 24 patients, high-grade squamous intraepithelial lesions in 28 patients, and squamous cell carcinoma (SQC) in 2 patients. Five patients with an original diagnosis of SQC had the diagnosis revised upon review of their specimens. It is noteworthy that these five specimens showed the presence of atypical parakeratotic cells. Thirty-two patients had anoscopic evaluation and 30 patients had histologic correlation. Twenty-seven patients with abnormal anoscopic findings had confirmed abnormal histologic findings. Twenty- five of the 32 (78%) patients had abnormal cytology that correlated with abnormal anoscopic findings. CONCLUSIONS: Anorectal cytology is an accurate method for screening patients for anal squamous lesions. Atypical parakeratotic cells represent a potential pitfall. Anoscopy is important in confirming the presence of a lesion, but only a biopsy can accurately determine the grade of a lesion.

Adult↗

PubMed2006

Predictors of invasion in patients with core-needle biopsy-diagnosed ductal carcinoma in situ and recommendations for a selective approach to sentinel lymph node biopsy in ductal carcinoma in situ.

BACKGROUND: Among patients with core-needle biopsy (CNB)-diagnosed ductal carcinoma in situ (DCIS), the guidelines for the selection of patients to undergo sentinel lymph node (SLN) biopsy are not well defined, and many patients with no invasion undergo an unnecessary SLN biopsy. The objective of this study was to identify the predictors of invasion in patients with CNB-diagnosed DCIS and, thus, to help determine the most appropriate candidates for SLN biopsy. METHODS: The authors retrospectively evaluated 200 consecutive patients with CNB-diagnosed DCIS who underwent final excision at their institution between May 1, 2002 and June 30, 2005. Demographic data, the size and type of lesion on imaging studies, histologic features of DCIS on CNB, the number of cores taken, and the number of cores involved by DCIS were correlated with invasion on excision and SLN biopsy outcome. RESULTS: Forty-one of 200 patients (21%) had invasive carcinoma diagnosed on final excision. Parameters that correlated with invasion were a mass lesion, lesion size >1.5 cm, high nuclear grade, and the presence of lobular cancerization on CNB. A multivariate logistic regression model was developed to predict invasion. At the time of breast surgery, 103 of 200 patients (52%) underwent SLN biopsy, and 34 had invasion diagnosed on final excision. Three patients had 1 positive SLN each. CONCLUSIONS: A mass lesion, lesion size >1.5 cm, and the presence of lobular cancerization on CNB were significant, independent predictors of invasion in patients with DCIS. The authors recommended the inclusion of these predictors in the guidelines for selecting patients for SLN biopsy to reduce the number of unnecessary procedures.

Biopsy, Needle↗

PubMedDate not supplied

Revenue-driven in TB control--three cases in China.

One quarter of all TB cases occur in China, which, during the past 20 years has moved from a planned economy to a socialist market economy. In the health sector, an important proportion of the financing originates from user payment. TB control is not an exception and different programmatic models are in place. This study examines, using a case study approach, three different TB programmes, one supposed to provide free service, one subsidized service and one with full cost recovery. The aim was to better understand the driving forces for programme performance in terms of case detection, case management and patient payments. The study found for all models that control and case management approaches were, to some extent, adapted to generate maximum income to the providers. The drive for income led to fewer cases detected, administration of unnecessary procedures and drugs, and a higher than necessary cost to the patients. The latter possibly leading to exclusion of poor people from the services. If user charges are to stay, TB control programmes need to be designed to take advantage of the financial incentives to improve performance. The referral system needs to be restructured, not to provide disincentives for good practices.

China↗

PubMed2000

Potential and pitfalls of sentinel node detection in breast cancer.

The last decade has seen the development of a minimally invasive technique to identify representative nodes--sentinel nodes--that reflect the tumor status of nodes in the axillary lymphatic basin draining a primary breast carcinoma. Sentinel lymph node dissection (SLND), originally developed as an alternative to elective complete lymph node dissection in patients with primary cutaneous melanoma, has been applied successfully to the management of patients with breast cancer. SLND holds promise as a staging technique to replace formal level I and II axillary lymph node dissection in selected patients with breast carcinoma, thus avoiding an unnecessary procedure that has no role in many patients with tumor-free axillae. Under way are two large randomized trials examining the role of SLND for the management of patients with invasive breast carcinoma. Even when tumor is detected in the sentinel node, a focused examination of this node may indicate whether or not completion axillary lymph node dissection is necessary. However, although SLND has great potential, its successful widespread use requires more stringent definition of the sentinel node and standardized guidelines for lymphatic mapping. Each institution must carefully assess the accuracy and consistency of results obtained by its multidisciplinary SLND team.

Axilla↗

PubMed1987

The role of computed tomography (CT) in the diagnosis of neurocysticercosis.

With the introduction of computed tomography (CT), the diagnosis of cysticercosis of the central nervous system (CNS) has been considerably improved. This is very important, especially for the countries in which the disease is still endemic. Plain skull radiographs or invasive procedures such as pneumography, ventriculography, and cerebral angiography can be used, but now CT has become the examination of choice because it is a safe, noninvasive, and accurate method thus making the other procedures unnecessary. In the present paper, 8,676 CT scans are reviewed from which 710 are selected patients with neurocysticercosis. CT has provided the diagnosis with greater precision than before. Its localization in the series was as follows: parenchymal, 473 patients, 65.2%; meningeal, 125 patients, 18.3%; mixed, 96 cases, 14%; intraventricular, 16 cases, 2.5%.

Adolescent↗

PubMed1983

Vincristine-induced megacolon.

Three cases of vincristine-induced megacolon are described with radiographic correlation. Vincristine is a widely used chemotherapeutic agent with neuropathic side effects causing colonic dilatation and constipation. The radiologist should be aware of this entity to prevent unnecessary procedures and, possibly, surgery.

Adult↗

PubMed1984

Advanced prostatic adenocarcinoma: biological aspects and effects of androgen deprivation achieved by castration or agonistic analogues of LHRH.

Twenty-nine patients with advanced prostatic adenocarcinoma were evaluated clinically, biochemically and radiologically and randomly assigned either to orchiectomy or to medical treatment. The latter consisted of the chronic administration of an LHRH agonistic analogue by parenteral and/or intranasal routes. Plasma testosterone levels fell to castrate values and remained so for as long as the follow-up lasted (24 months); estrogen levels fell as well. No change in basal cortisol, thyroxine or prolactin levels was noticed. A decrease in prostate size and improvement in prostatism occurred in all. Bone pain and radiology conventionally or by isotopic scanning, did not parallel the improvement seen in the primary disease locus. Similarly, the changes in alkaline phosphatase were minimal when compared to that of prostatic acid phosphatase. Both enzymes increased prior to or concurrently with relapse of the disease. The longest remission and survival was seen in patients with low enzyme levels, non diffuse bone metastases and high degree of tumor differentiation. Chronic use of agonistic analogues of LHRH induces effective castration in men with prostatic carcinoma and can replace orchiectomy or estrogen administration. The quantitative analysis of androgen receptors (AR) in subcellular fractions of tumor cells; the use of techniques to enhance the number of AR in the cytosol; and the determination of the type II/I regulatory subunit of protein kinase may be used to identify hormone independent clones and spare patients of unnecessary procedures.

Acid Phosphatase↗

PubMed2000

[Management of mid-facial fractures].

In the past, treatment of maxillofacial fractures was characterized by low incidences of midface fractures, while severe cases were associated with a high death rate. Over the last decades the application of new techniques has provided a successful outcome in the management of these more frequently observed injuries. With the introduction of antibiotics and the principles of modern anesthesiology, conservative methods of fracture treatment such as intermaxillary fixation and the application of extension devices were increasingly replaced by surgical techniques. The development of different osteosynthesis plate and screw systems in the early 1970s has made three-dimensional reconstruction a standard of care in the surgical treatment of midface fractures. With the recent introduction of commercially available bioresorbable systems, removal of osteosynthesis material has become an unnecessary procedure. Further research in innovative techniques of maxillofacial surgery and imaging, such as image-guided surgery by computer navigation, may be warranted to minimize surgical approaches and decrease incidences of perioperative morbidity.

Adult↗

PubMed2002

[Influence of the reimbursement system on medical quality].

BACKGROUND: The relationship between reimbursement for medical care and the quality of medicine is mostly discussed if there are warnings about underuse as a consequence of underpayment. By various examples it can be illustrated that not only a lack of services but also an overuse of medical care may be hazardous and reduce quality in medicine. This relates to the risk, which is part of each medical intervention. PRESENT SITUATION: The introduction of the Diagnosis Related Groups (DRGs) in Germany is at present mostly discussed under the aspect of a possible risk of underuse. On the other hand, there are chances for the quality of medicine as a result from a lean diagnostic and therapy, which will be the consequence of economic changes induced by the DRGs. A guideline-oriented medicine will often avoid unnecessary procedures and thereby improve the quality of medical services. CONCLUSION: Loss of quality and improvement of quality arise in the field of medicine from overuse as well as from underuse. Most important for an optimal quality is a quantitatively appropriate treatment. In general, we observe that medical decisions are more and more oriented on economic frames. It has to be observed during forthcoming years to what extent ethical problems arise by this situation.

Germany↗