RESUMEN
BACKGROUND: There is little evidence for solutions to improve the handoff process between units, particularly from the emergency department (ED) to the inpatient unit. A systematic approach was used to improve the handoff communication process between the ED and the four private physician groups serving Juneau, Alaska, that admit and deliver care to patients of a 73-bed, Level 4 trauma center community hospital. METHODS: Data were collected in using the Joint Commission Center for Transforming Healthcare's Targeted Solutions Tool (®)(TST(®)) to determine the rate of defective handoff communications and the factors that contributed to those defective handoff communications. Targeted solutions were then implemented to specifically address the identified contributing factors. RESULTS: A random sample of 107 handoff opportunities was collected during the baseline phase (November 4, 2011- January 12, 2012) to measure performance and identify the contributing factors that led to defective handoffs. The baseline handoff communications defective rate was 29.9% (32 defective handoffs/107 handoff opportunities). The top four contributing factors, together accounting for 69.8% of all the causes of defective handoffs, were inaccurate/incomplete information, method ineffective, no standardized procedures for an effective handoff, and the person initiating the handoff, known as the "sender," lacks knowledge about the patient. After implementation of targeted solutions to the identified contributing factors, the handoff communications defective rate for the "improve" phase (April 1, 2012-July 29, 2012) was reduced from baseline by 58.2% to 12.5% (13 defective handoffs/104 handoff opportunities), p = 0.002; 2-proportions test. The number of adverse events related to hand-off communications declined as the handoff communications defective rate improved. CONCLUSION: Use of the TST was associated with improvement in the ED handoff communication process.
Asunto(s)
Comunicación , Servicio de Urgencia en Hospital/organización & administración , Hospitales Comunitarios/organización & administración , Pase de Guardia/organización & administración , Mejoramiento de la Calidad/organización & administración , Protocolos Clínicos/normas , Registros Electrónicos de Salud/organización & administración , Servicio de Urgencia en Hospital/normas , Hospitales Comunitarios/normas , Humanos , Pase de Guardia/normas , Mejoramiento de la Calidad/normasRESUMEN
OBJECTIVES: We wanted to assess the diagnostic accuracy of urinary dipstick testing in excluding catheter-associated urinary tract infection (CAUTI) in intensive care unit (ICU) patients with fever or hypothermia. METHODS: This was a prospective observational cohort study in a medical-surgical ICU. Patients with new-onset fever >38.3 °C or hypothermia <36 °C at least 48 h after urinary catheter insertion were included over a 2-year period. At each episode, a urinary dipstick test and a urine culture were performed as the criterion standard. Extensive microbiological investigations for extra-urinary infections were performed also. The performances of various urinary dipstick result combinations in ruling out CAUTI were compared based on the likelihood ratios (LR+ and LR-). RESULTS: Symptomatic CAUTI was diagnosed in 31 (24.4 %) of the 127 included patients (195 episodes of fever or hypothermia). LR+ was best for combined leukocyte esterase-positive and nitrite-positive dipstick results (overall population: 14.91; 95 % confidence interval [95 % CI], 5.53-40.19; patients without urinary symptoms: 15.63; 95 % CI, 5.76-42.39). LR- was best for either leukocyte esterase-positive or nitrite-positive dipstick results (overall population: 0.41; 95 % CI, 0.57-0.65; patients without urinary symptoms, 0.36; 95 % CI, 0.21-0.60). CONCLUSIONS: Urinary dipstick testing at the bedside does not help to rule out symptomatic CAUTI in medical or surgical ICU patients with fever or hypothermia.
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Infecciones Relacionadas con Catéteres/diagnóstico , Fiebre de Origen Desconocido/etiología , Hipotermia/etiología , Sistemas de Atención de Punto , Infecciones Urinarias/diagnóstico , Orina/química , Adulto , Hidrolasas de Éster Carboxílico/análisis , Estudios de Cohortes , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Técnicas Microbiológicas , Persona de Mediana Edad , Nitritos/análisis , Estudios Prospectivos , Orina/microbiologíaRESUMEN
OBJECTIVES: Efficient empiric antibiotic therapy remains the cornerstone of sepsis treatment. However, antibiotics could be responsible for the transient clinical deterioration provoked by the release of bacterial cell-wall constituents, such as endotoxin, into the blood stream. The aim of this study was to evaluate if a transient elevation of endotoxin level occurred in septic patients following antibiotic administration. METHODS: Thirty-three septic intensive care unit (ICU) patients were enrolled in this prospective trial. Four blood samples were collected from each of these patients during a 24-h period, and endotoxin activity was measured in these samples by the chemiluminescence technique. Fifteen ICU non-septic patients and 15 healthy volunteers were also observed for possible daily fluctuations in endotoxin activity. RESULTS: There was no significant increase in endotoxin levels following the initiation of empiric antibiotic therapy in septic patients. A clinical deterioration in the 4 h following antibiotic administration was observed in 14 septic patients (42 %). These patients had significantly higher endotoxin levels than stable septic patients. CONCLUSIONS: Although endotoxin levels failed to increase after the administration of antibiotic(s) to critically ill patients, they were higher in the septic patients presenting a transient deterioration than in the other patients. This observation suggests that a possible release of endotoxin due to bacteria lysis by antibiotics could be responsible for the observed clinical deterioration.
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Antibacterianos/uso terapéutico , Endotoxinas/análisis , Plasma/química , Sepsis/tratamiento farmacológico , Sepsis/patología , Adulto , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos , Mediciones Luminiscentes , Masculino , Persona de Mediana Edad , Estudios ProspectivosAsunto(s)
Medicina Basada en la Evidencia , Melanoma/cirugía , Educación del Paciente como Asunto , Neoplasias Cutáneas/cirugía , Humanos , Escisión del Ganglio Linfático , Metástasis Linfática , Masculino , Melanoma/patología , Persona de Mediana Edad , Biopsia del Ganglio Linfático Centinela , Neoplasias Cutáneas/patologíaRESUMEN
Transient splenial lesions of the corpus callosum have been mainly reported in epileptic patients. We report the case of a non-epileptic woman with bipolar affective disorder treated by oxcarbazepine which was withdrawn because of a mild hyponatremia (128 mmol/l). A confusional state followed withdrawal and the electroencephalogram was free of spike or sharp waves. Brain MRI showed a single splenial lesion of the corpus callosum revealed by a high intensity T2 signal on FLAIR and diffusion sequences. Because of a major depressive episode, twelve sessions of electroconvulsive therapy were performed and yielded clinical improvement. A second brain MRI performed 5 weeks later was normal. The relevances of this cases are the non-epileptic status of the patient, the drug incriminated (oxcarbazepine), and the normalisation of brain MRI despite electroconvulsive therapy. Different mechanisms of this brain MRI abnormality are discussed including the sudden withdraw of oxcarbazepine. Prognosis of transient splenial lesions of the corpus callosum is good. Clinicians should search for recent metabolic disorders and therapeutic modifications.
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Trastorno Bipolar/patología , Cuerpo Calloso/patología , Antimaníacos/uso terapéutico , Carbamazepina/análogos & derivados , Carbamazepina/uso terapéutico , Imagen de Difusión por Resonancia Magnética , Terapia Electroconvulsiva , Femenino , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , OxcarbazepinaRESUMEN
A 61-year old man was admitted in our hospital for distal ischaemic lesions of the right foot with necrosis of the fifth toe. The lesions appeared a few days before admission. He was known for severe atheromatous disease and multiple aortic and femoro-popliteous aneurysms. He presented also numerous cardiovascular risk factors and a terminal chronic kidney disease was found 18 months earlier. The etiology of the kidney disease was not clear. The patient received hemodialysis since one month. We suspected a severe peripheral arterial disease but the investigations showed preserved distal arterial blood flow what made us think about a thromboembolic disease. We ruled out a potential embolic cardiopathy and, after finding eosinophilia and a previous consultation report of livedo, we suggested the diagnosis of cholesterol crystal embolisation. It was confirmed by the macroscopic examination of the necrotic toe. It's a rare and under-diagnosed pathology with a variable presentation. Though, it's important to detect this affection early as possible to prevent the frequent recurrences. The acute mortality is about 15%. There is no specific treatment, but an an aggressive control of the atheromatous disease is important. We must also avoid the known potential triggering factors: vascular surgery, angiography and anticoagulant or thrombolytic medications.
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Embolia por Colesterol/complicaciones , Isquemia/complicaciones , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Diálisis Renal , Antihipertensivos/uso terapéutico , Humanos , Claudicación Intermitente/etiología , Isquemia/patología , Masculino , Persona de Mediana Edad , Necrosis , Dedos del Pie/patologíaAsunto(s)
Colitis Isquémica/diagnóstico por imagen , Colon/irrigación sanguínea , Infarto/diagnóstico por imagen , Perforación Intestinal/diagnóstico por imagen , Peritonitis/diagnóstico por imagen , Tomografía Computarizada Espiral , Dolor Abdominal/etiología , Anciano , Colectomía , Colitis Isquémica/cirugía , Colon/patología , Urgencias Médicas , Heces , Humanos , Infarto/cirugía , Perforación Intestinal/cirugía , Masculino , Necrosis , Peritonitis/cirugíaAsunto(s)
Enfermedades de la Mama , Enfermedades de la Mama/diagnóstico , Adulto , Biopsia con Aguja , Enfermedades de la Mama/etiología , Enfermedades de la Mama/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Hiperplasia , Mamografía , Dolor/etiología , Células del Estroma/patología , Ultrasonografía MamariaRESUMEN
The goal of this pictorial essay is to review the typical and less typical appearances of recurrent and metastatic renal cell carcinoma. Spiral computed tomography is the method of choice to evaluate the postsurgical nephrectomy site and usual sites of metastases.
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Carcinoma de Células Renales/diagnóstico por imagen , Neoplasias Renales/diagnóstico por imagen , Metástasis de la Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/secundario , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/secundario , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/cirugía , Humanos , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Metástasis Linfática/diagnóstico por imagen , Nefrectomía , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/secundario , Factores de RiesgoRESUMEN
PURPOSE: To evaluate the ability of breast ultrasound to detect and analyze small (less than 1 cm in size) invasive lobular carcinomas. MATERIAL: and methods. A retrospective analysis of 93 small invasive carcinomas measuring less than 10 mm in size diagnosed between 1998 and 2000 in our institution was performed. In this group, 15 invasive lobular carcinomas were identified in 12 patients. All mammograms and ultrasound examinations were reviewed. RESULTS: Twelve cases of less than 10 mm invasive lobular carcinomas were diagnosed. Two lesions in one patient and one in an other patient were not detected at ultrasound and mammogram (multifocal carcinomas). All invasive lobular carcinomas were found as hypoechogenic masses with ill-defined margins and posterior shadowing. Four lesions showed evidence of microlobulations, 6 lesions an hyperechogenic halo and only one showed a vertical axis. The sensitivity of ultrasound in this group was recorded as 80% (12/15). CONCLUSION: The study confirms a high sensitivity of ultrasound examination in detection and characterization of small infiltrative lobular carcinoma.
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Neoplasias de la Mama/diagnóstico por imagen , Carcinoma Lobular/diagnóstico por imagen , Anciano , Neoplasias de la Mama/patología , Carcinoma Lobular/patología , Femenino , Humanos , Persona de Mediana Edad , Invasividad Neoplásica , Estudios Retrospectivos , UltrasonografíaAsunto(s)
Celulitis (Flemón)/etiología , Cuerpos Extraños/complicaciones , Perforación Intestinal/complicaciones , Muslo , Anciano , Celulitis (Flemón)/diagnóstico por imagen , Celulitis (Flemón)/microbiología , Resultado Fatal , Humanos , Perforación Intestinal/diagnóstico por imagen , Masculino , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE OF THE STUDY: To underline value of the preoperative splenic embolization with haemostatic aim to facilitate partial splenectomy. MATERIAL: Observation of a 23-year-old woman, admitted for pain, anemia, and mass of the left hypochondrium. Sonography, helical CT and MRI showed that the bulky mass was developed from the upper pole of spleen, and dislodged the left kidney towards the pelvis. This mass had fibrous characteristics in favour of a primary lesion with recent bleeding and was compatible with a splenic hamartoma. METHODS: Selective partial splenic embolization with haemostatic aim using metal coils, immediately followed by surgery. RESULTS: Preoperative embolisation made possible to carry out under optimal surgical conditions a partial splenectomy with en-bloc resection of the splenic mass. Histologic diagnosis was splenic hamartoma of pulpar type. CONCLUSION: This case illustrates the interest of accurate characterization of splenic lesions by several imaging techniques allowing indication for conservative surgery, and of preoperative embolization facilitating a partial splenectomy.
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Embolización Terapéutica/métodos , Hamartoma/cirugía , Esplenectomía/métodos , Enfermedades del Bazo/cirugía , Adulto , Femenino , Hamartoma/patología , Humanos , Enfermedades del Bazo/patología , Resultado del TratamientoRESUMEN
This survey was performed using data generated by a mailing sent with the collaboration of regional coordinators in 2002 to all the nephrologists identified in France. 1326 nephrologists were included in the pool, with an average of 22 nephrologists per million population (pmp), ranging from 14 to 29 pmp according to the different regions. Their mean (and median) age was 46.6 years, 30% were female. 63.5% of the nephrologists were working in a public hospital, 19.3% in private clinics, 13.3% in non-profit associations, 2% and 0.4% in research units or with industry, respectively. The data were used to generate a register of all the French nephrologists. 47 retirements per year are anticipated between 2010 and 2019, which yields an indication for the number of new nephrologists to be certified in this time-span. The gap between the future retirees and the newly trained nephrologists is very deep and cannot be bridged with the currently operating modes of recruitment. The increasing incidence and prevalence of patients with end stage renal failure will considerably increase the need of nephrologists, which is all the more amplified by the recent modification of the French law concerning the weekly upper limit of working time for physicians. Urgent measures have to be taken for preventing the consequences of dearth of nephrologists clearly anticipated for the next 10 years.
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Nefrología , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Nefrología/estadística & datos numéricos , Encuestas y Cuestionarios , Recursos HumanosRESUMEN
OBJECTIVES: The purpose of this study was to determine clinical and imaging findings associated with malignancy in pheochromocytomas. MATERIAL: and methods. A multicentric retrospective CT study including 50 lesions (23 benign and 27 malignant histologically proven pheochromocytomas) was conducted. The diagnosis of malignancy was based on histological criteria (capsular rupture, local invasion), on synchronous metastases or on the occurrence of locoregional recurrences or metastases during the outcome. The analysis was based on clinical data (age, sex, secretion of the lesion and hypertension) and on radiological criteria (largest diameter of the tumor, side, homogeneity, regularity and sharpness of contours). RESULTS: A statistical difference was found between the median largest diameter, the regularity and sharpness of contours benign and malignant lesions (p<0.0001); other clinical and radiological criteria being non significantly different. A largest diameter greater than 45 mm enabled to suggest malignancy with a sensitivity of 100% and a specificity of 69%. CONCLUSION: A diameter larger than 50mm, presence of a locoregional invasion and of metastases are strong arguments favouring.
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Neoplasias de las Glándulas Suprarrenales/diagnóstico por imagen , Feocromocitoma/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Adolescente , Neoplasias de las Glándulas Suprarrenales/clasificación , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/cirugía , Adulto , Edad de Inicio , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hipertensión/etiología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Feocromocitoma/clasificación , Feocromocitoma/complicaciones , Feocromocitoma/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/normasAsunto(s)
Cuerpos Extraños/diagnóstico por imagen , Mamografía , Complicaciones Posoperatorias/diagnóstico por imagen , Tapones Quirúrgicos de Gaza , Ultrasonografía Mamaria , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/cirugía , Carcinoma Adenoide Quístico/diagnóstico , Carcinoma Adenoide Quístico/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnósticoRESUMEN
The need for adrenal gland biopsy has much decreased since CT and MR criteria have been introduced for further characterization of adrenal lesions. Several diagnostic criteria have been described for characterization of benign versus malignant adrenal lesions based on density measurements and contrast wash-out. Adrenal biopsy may be indicated for lesions that remain indeterminate in nature after CT and MRI. Such lesions include those with a percentage of wash-out near the 50% threshold or lesions that have increased in size at follow-up imaging in spite of their benign appearance based on density measurement at prior CT evaluation. The location of the adrenal glands has an impact on the technical difficulties during biopsy and the types of complications. Ipsilateral lateral decubitus seems the more logical approach and can be used for right or left adrenal lesions; this approach is generally well tolerated by patients. Biochemical evaluation should be performed prior to biopsy in order to exclude pheochromocytoma. The overall accuracy of adrenal biopsy, considering both positive predictive value and negative predictive value, compared to the gold standard is between 80 and 95% with a complication rate of about 10%.
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Enfermedades de las Glándulas Suprarrenales/patología , Enfermedades de las Glándulas Suprarrenales/diagnóstico por imagen , Algoritmos , Biopsia/métodos , Humanos , Tomografía Computarizada por Rayos XRESUMEN
The authors describe the case of a patient presenting miliary involvement of the lung due to mycobacterium bovis after intravesical BCG administration. After initial transurethral resection, the patient was treated with immunotherapy by intravesical instillation of BCG and received 9 treatments without any problem. After the 10th treatment, the patient presented with cough and signs of urinary infection. At admission the chest radiograph showed a miliary pattern, better seen at high resolution CT, and using helical technique with the maximum intensity projection (MIP) reconstructions. MIP demonstrated to better advantage the well defined contours of the nodules, distributed evenly and randomly in the whole lung. After anti-TB treatment, the patient had regained full activity with persistence of the miliary pattern but a decreased number and size of nodules and calcification in some of them. This case illustrates a rare complication of intravesical immunotherapy, and points out the superiority of Sliding Thin Slab MIP (STS-MIP) compared with standard HRCT which allows a better detection of extent and follow-up of a military pattern, notably in moderate forms, by improvement of the anatomical resolution.