RESUMEN
OBJECTIVE: Early admission to hospital with minimum delay is a prerequisite for successful management of acute stroke. We sought to determine our local pre- and in-hospital factors influencing this delay. PATIENTS AND METHODS: Time from onset of symptoms to admission (admission time) was prospectively documented during a 6-month period (December 2004 to May 2005) in patients consecutively admitted for an acute focal neurological deficit presented at arrival and of presumed vascular origin. Mode of transportation, patient's knowledge and correct recognition of stroke symptoms were assessed. Physicians contacted by the patients or their relatives were interviewed. The influence of referral patterns on in-hospital delays was further evaluated. RESULTS: Overall, 331 patients were included, 249 had an ischaemic and 37 a haemorrhagic stroke. Forty-five patients had a TIA with neurological symptoms subsiding within the first hours after admission. Median admission time was 3 hours 20 minutes. Transportation by ambulance significantly shortened admission delays in comparison with the patient's own means (HR 2.4, 95% CI 1.6-3.7). The only other factor associated with reduced delays was awareness of stroke (HR 1.9, 95% CI 1.3-2.9). Early in-hospital delays, specifically time to request CT-scan and time to call the neurologist, were shorter when the patient was referred by his family or to a lesser extent by an emergency physician than by the family physician (p < 0.04 and p < 0.01, respectively) and were shorter when he was transported by ambulance than by his own means (p < 0.01). CONCLUSIONS: Transportation by ambulance and referral by the patient or family significantly improved admission delays and early in-hospital management. Correct recognition of stroke symptoms further contributed to significant shortening of admission time. Educational programmes should take these findings into account.
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Urgencias Médicas , Admisión del Paciente , Accidente Cerebrovascular/terapia , Enfermedad Aguda , Anciano , Femenino , Humanos , Masculino , Médicos , Derivación y Consulta , Encuestas y Cuestionarios , Factores de Tiempo , Transporte de PacientesRESUMEN
OBJECTIVE: The purpose of this study was to assess the effect of i.v. administration of N-acetylcysteine (NAC) on serum levels of creatinine and cystatin C, two markers of renal function, in patients with renal insufficiency who undergo emergency contrast-enhanced CT. SUBJECTS AND METHODS: Eighty-seven adult patients with renal insufficiency who underwent emergency CT were randomized to two groups. In the first group, in addition to hydration, patients received a 900-mg injection of NAC 1 hour before and another immediately after injection of iodine contrast medium. Patients in the second group received hydration only. Serum levels of creatinine and cystatin C were measured at admission and on days 2 and 4 after CT. Nephrotoxicity was defined as a 25% or greater increase in serum creatinine or cystatin C concentration from baseline value. RESULTS: A 25% or greater increase in serum creatinine concentration was found in nine (21%) of 43 patients in the control group and in two (5%) of 44 patients in the NAC group (p = 0.026). A 25% or greater increase in serum cystatin C concentration was found in nine (22%) of 40 patients in the control group and in seven (17%) of 41 patients in the NAC group (p = 0.59). CONCLUSION: On the basis of serum creatinine concentration only, i.v. administration of NAC appears protective against the nephrotoxicity of contrast medium. No effect is found when serum cystatin C concentration is used to assess renal function. The effect of NAC on serum creatinine level remains unclear and may not be related to a renoprotective action.
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Acetilcisteína/administración & dosificación , Lesión Renal Aguda , Creatinina/sangre , Cistatinas/sangre , Yohexol/análogos & derivados , Tomografía Computarizada por Rayos X/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/prevención & control , Adulto , Biomarcadores/sangre , Medios de Contraste/efectos adversos , Cistatina C , Servicios Médicos de Urgencia/métodos , Femenino , Humanos , Inyecciones Intravenosas/efectos adversos , Yohexol/efectos adversos , Masculino , Resultado del TratamientoRESUMEN
Effective faculty development workshops are essential to develop and sustain the quality of faculty's teaching. In an integrated problem-based curriculum, tutors expressed the needs to further develop their skills in facilitating students' content learning and small-group functioning. Based on the authors' prior observations that tutors' performance depends on their teaching context, a workshop was designed not only tailored to the tutors' needs but also organized within their respective teaching unit. The purposes of this study are (1) to evaluate whether this workshop is effective and improves tutors' teaching skills, and (2) to assess whether workshop effectiveness depends on tutors' performance before the workshop and on their teaching unit environment. Workshop effectiveness was assessed using (a) tutors' perception of workshop usefulness and of their improvement in tutorial skills, and (b) students' ratings of tutor performance before and after the workshop. In addition, an analysis of variance model was designed to analyse how tutors' performance before the workshop and their teaching unit influence workshop effectiveness. Tutors judged the workshop as helpful in providing them with new teaching strategies and reported having improved their tutorial skills. Workshop attendance enhanced students' ratings of tutors' knowledge of problem content and ability to guide their learning. This improvement was also long-lasting. The workshop effect on tutor performance was relative: it varied across teaching units and was higher for tutors with low scores before the workshop. A workshop tailored to tutors' needs and adapted to their teaching unit improves their tutorial skills. Its effectiveness is, however, influenced by tutors' level of performance before the workshop and by the environment of their teaching unit. Thus, to be efficient, the design of a workshop should consider not only individual tutors' needs, but also the background of their teaching units, with special attention to their internal organization and tutor group functioning.
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Curriculum , Educación Médica , Educación , Docentes , Competencia Profesional , Enseñanza/normas , Análisis de Varianza , Actitud , Educación/normas , Humanos , Aprendizaje Basado en Problemas , Autoimagen , Estudiantes de Medicina/psicología , Encuestas y CuestionariosRESUMEN
BACKGROUND AND OBJECTIVES: (1) to evaluate the performance of emergency department triage; (2) to explore the variability of the triage process; and (3) to examine the reliability of a four-level triage scale, using an interactive triage simulator. METHODS: We developed 22 interactive computerized vignettes describing patients presenting at the Emergency Department. Each vignette displayed the presenting complaint and offered the possibility to ask questions and obtain vital signs before deciding on the triage severity rating. The vignettes were rated twice by 45 nurses and 8 physicians. RESULTS: (1) The concordance between the observed triage decision and an expert-attributed emergency level was perfect in 58% of the situations. Triage acuity was overestimated in 11%, and underestimated in 31%. (2) There was a wide variability in the triage process across observers and vignettes. The mean number of questions varied from 1.77 to 18.95 across individuals, and from 3.96 to 11.60 across vignettes. (3) Finally, the test-retest reliability of our instrument was good (weighted kappa = 0.82) but the interrater reliability was moderate (weighted kappa = 0.41). CONCLUSIONS: The computerized triage simulator is an innovative tool to evaluate the process and the performance of triage and to evaluate the reliability of a triage instrument.
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Servicio de Urgencia en Hospital , Evaluación de Procesos y Resultados en Atención de Salud/métodos , Triaje , Adulto , Anciano , Simulación por Computador , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de la Atención de Salud , Reproducibilidad de los Resultados , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVES: To evaluate a low-dose abdominal computed tomography (LDCT) protocol, delivering a radiation dose close to that delivered by an abdominal plain film (APF), in patients with a clinical suspicion of renal colic. METHODS: A total of 139 patients for whom an APF was requested for suspicion of renal colic were randomized into two groups. The patients in group 1 (n = 68) underwent an admission LDCT scan delivering a 2.1-mSv radiation dose to women and 1.6 mSv to men, instead of the APF. Patients in group 2 (n = 71) underwent an APF. Clinical and radiologic follow-up data were obtained for each patient. The number of additional abdominal ultrasound and CT scans performed to reach a confident final diagnosis and determine the proper treatment was compared between the two groups. A mean effective radiation dose was obtained in each group. RESULTS: Of the 68 patients in group 1 (LDCT), 10 (15%) underwent ultrasonography, 9 (13%) conventional abdominal CT, and 2 (3%) both. In group 2 (APF), the corresponding percentages were 27% (19 of 71), 28% (20 of 71), and 23% (16 of 71). Of the 68 patients in group 1, 47 (69%) did not require any additional examinations compared with 16 (23%) of the 71 patients in group 2 (P < 0.0001). The mean effective dose was 3.5 and 6.9 mSv in groups 1 and 2, respectively (P < 0.0001). CONCLUSIONS: In patients with suspicion of renal colic, replacing the admission APF with our LDCT protocol will significantly reduce the need for additional CT or ultrasonography. Also, our LDCT protocol decreases by almost 50% the mean radiation dose per patient.
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Cólico/diagnóstico por imagen , Enfermedades Renales/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dosis de Radiación , Radiografía AbdominalRESUMEN
STUDY OBJECTIVE: We compare the performance of a wrist blood pressure oscillometer with the mercury standard in the triage process of an emergency department (ED) and evaluate the impact of wrist blood pressure measurement on triage decision. METHODS: Blood pressure was successively measured with the standard mercury sphygmomanometer and with the OMRON-RX-I wrist oscillometer in a convenience sample of 2,493 adult patients presenting to the ED with non-life-threatening emergencies. Wrist and mercury measures were compared using criteria of the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS). The impact on triage decisions was evaluated by estimating the rate of changes in triage decisions attributable to blood pressure results obtained with the wrist device. RESULTS: Wrist oscillometer failed to meet the minimal requirements for recommendation by underestimating diastolic and systolic blood pressure. Mean (+/-SD) differences between mercury and wrist devices were 8.0 mm Hg (+/-14.7) for systolic and 4.2 mm Hg (+/-12.0) for diastolic measures. The cumulative percentage of blood pressure readings within 5, 10, and 15 mm Hg of the mercury standard was 32%, 58%, and 72% for systolic, and 40%, 67%, and 83% for diastolic measures, respectively. Using the wrist device would have erroneously influenced the triage decision in 7.6% of the situations. The acuity level would have been overestimated in 2.2% and underestimated in 5.4% of the triage situations. CONCLUSION: The performance of the OMRON-RX-I wrist oscillometer does not fulfill the minimum criteria of AAMI and BHS compared with mercury standard in the ED triage setting.
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Determinación de la Presión Sanguínea/instrumentación , Servicio de Urgencia en Hospital , Triaje/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oscilometría/instrumentación , Esfigmomanometros , MuñecaRESUMEN
QUESTION UNDER STUDY: Elderly patients represent an increasing proportion of emergency department (ED) admissions. When no specific complaint is identified, the reason for referral is commonly called "home care impossible". The aim of this study was to describe a population of elderly patients who present to the ED of a 1200-bed university hospital without specific complaint, and to assess how they were evaluated in the ED. METHODS: Data on triage, mode of admission and discharge were collected. After the initial evaluation in the ED, patients were classified in two categories: (1) patients identified with a medical problem requiring rapid care or investigation, (2) patients without a medical problem considered as true "home care impossible". These latter patients underwent a complete assessment using the Minimal Data Set-Home Care (MDS-HC). RESULTS: During the 10-week study period 253 patients (mean age 81 years) were referred because of "home care impossible". An acute medical problem was identified in 129 of those patients (51%). All these patients were triaged in lower acuity categories. 33 (26%) were undertriaged due to (1) absence of vital signs measurement, (2) poor recognition of neurological symptoms, (3) atypical clinical presentation. The remaining patients were considered as true "home care impossible". The MDS-HC evaluation revealed a high level of biopsychosocial comorbidities. CONCLUSIONS: Frail elderly patients admitted without specific complaints are at risk of inappropriate or delayed evaluation due to undertriage at the door of the ED. A more specific geriatric assessment should be integrated early in the triage process of these patients.
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Servicio de Urgencia en Hospital , Anciano Frágil , Evaluación Geriátrica , Triaje , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Femenino , Necesidades y Demandas de Servicios de Salud , Hospitales Universitarios , Humanos , Masculino , Evaluación de Resultado en la Atención de Salud , Admisión del Paciente , Alta del Paciente , SuizaRESUMEN
OBJECTIVES: The precise identification of many diseases of the gastrointestinal tract requires the histological analysis of multiple biopsies of the lining mucosae, thus preventing an immediate diagnosis and the safe screening of the entire organ. To address these limitations, we developed a novel spectroscopic procedure for a real-time, non-invasive optical analysis of mucosae. METHODS: We have used a fibre-optic probe that monitors light propagation through small tissue volumes to evaluate the antral and fundic mucosa of 51 patients that underwent gastroscopy for symptoms of dyspepsia. Several optical coefficients were computed from the recorded light reflectance, and confronted to the diagnosis made by an expert gastroscopist at the time of the clinical examination. Both evaluations were then validated by comparison with the histological diagnosis of a pathologist who screened biopsies taken at the sites of the optical measurements. RESULTS: We report that the optical procedure discriminated normal and pathological gastric mucosae with a higher sensitivity and specificity than endoscopic diagnosis. We also show that the changes in light-scattering coefficient, which permitted the optical diagnosis of gastritis alterations, were indirectly correlated with the extent of inflammatory infiltration of the mucosa and detected mucosal alterations mild enough to escape endoscopic detection. CONCLUSIONS: The results show that, in a normal clinical setting, the optical in vivo analysis provided by our system detects alterations typical of gastritis, and allow for their graded scoring with a specificity and sensitivity that compare well with those of standard histology, while avoiding the invasiveness of the latter procedure. The method is adaptable to the screening of other types of lesions and mucosae and, hence, should prove useful in improving available diagnostic approaches.
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Técnicas de Diagnóstico del Sistema Digestivo , Gastritis/patología , Técnicas de Diagnóstico del Sistema Digestivo/instrumentación , Femenino , Tecnología de Fibra Óptica/métodos , Fundus Gástrico/patología , Mucosa Gástrica/patología , Gastroscopía/métodos , Humanos , Luz , Masculino , Persona de Mediana Edad , Antro Pilórico/patología , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: To evaluate primary care physicians' knowledge of guidelines for the management of COPD. METHOD: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. RESULTS: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. CONCLUSIONS: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.
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Competencia Clínica , Guías de Práctica Clínica como Asunto , Atención Primaria de Salud , Enfermedad Pulmonar Obstructiva Crónica/terapia , Adolescente , Adulto , Niño , Preescolar , Estudios Transversales , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
OBJECTIVE: The objective of our study was to prospectively evaluate whether a second-generation sonography contrast agent (SonoVue) can improve the conspicuity of solid organ injuries (liver; spleen; or kidney, including adrenal glands) in patients with blunt abdominal trauma. SUBJECTS AND METHODS: Two hundred ten consecutive hemodynamically stable trauma patients underwent both abdominal sonography and CT at admission. The presence of solid organ injuries and the quality of sonography examinations were recorded. Patients with false-negative sonography findings for solid organ injuries in comparison with CT results underwent control sonography. If a solid organ injury was still undetectable, contrast-enhanced sonography was performed. Findings of admission, control, and contrast-enhanced sonograms were compared with CT results for their ability to depict solid organ injuries. Contrast-enhanced sonography was also performed in patients in whom a vascular injury (pseudoaneurysm) was shown on admission or control CT. RESULTS: CT findings were positive for 88 solid organ injuries in 71 (34%) of the 210 patients. Admission, control, and contrast-enhanced sonograms had a detection rate for solid organ injury of 40% (35/88), 57% (50/88), and 80% (70/88), respectively. The improvement in the detection rate between control and contrast-enhanced sonography was statistically significant (p = 0.001). After exclusion of low-quality examinations, contrast-enhanced sonography still missed 18% of solid organ injuries. Five vascular liver (n = 1) and spleen (n = 4) injuries (pseudoaneurysms) were detected on CT; all were visible on contrast-enhanced sonography. CONCLUSION: Contrast-enhanced sonography misses a large percentage of solid organ injuries and cannot be recommended to replace CT in the triage of hemodynamically stable trauma patients. However, contrast-enhanced sonography could play a role in the detection of pseudoaneurysms.
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Traumatismos Abdominales/diagnóstico por imagen , Medios de Contraste , Fosfolípidos , Hexafluoruro de Azufre , Vísceras/lesiones , Heridas no Penetrantes/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía , Vísceras/diagnóstico por imagenRESUMEN
We describe the case of a woman, who had previously undergone tubal sterilization, and later experienced two episodes of orthostatic hypotension during menstruation, as a result of an ectopic pregnancy.
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Medicina de Emergencia/métodos , Embarazo Ectópico/complicaciones , Embarazo Ectópico/diagnóstico , Síncope/etiología , Abdomen/diagnóstico por imagen , Dolor Abdominal/etiología , Adulto , Femenino , Humanos , Embarazo , Pruebas de Embarazo , Embarazo Ectópico/cirugía , Esterilización Reproductiva , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND: Low fat-free mass may be an independent risk factor for malnutrition that results in an increased length of hospital stay (LOS). OBJECTIVES: The objectives were to compare differences in fat-free mass and fat mass at hospital admission between patients and healthy control subjects and to determine the association between these differences and the LOS. DESIGN: Patients (525 men, 470 women) were prospectively recruited at hospital admission. Height-corrected fat-free mass and fat mass (fat-free-mass index or fat-mass index; in kg/m2) were determined in patients at admission by bioelectrical impedance analysis and were compared with values for sex-, age-, and height-matched control subjects. Patients were classified as well-nourished, moderately depleted, or severely depleted on the basis of a Subjective Global Assessment questionnaire and a body mass index (in kg/m2) < or > 20. RESULTS: Low fat-free mass was noted in 37% and 55.6% of patients hospitalized 1-2 d and > 12 d, respectively. The odds ratios were significant for fat-free-mass index and were higher in patients with a LOS of > 12 d [men (odds ratio: 5.6; 95% CI: 3.1, 10.4), women (4.4; 2.3, 8.7)] than in those with a LOS of 1-2 d [men (3.3; 2.2, 5.0), women (2.2; 1.6, 3.1)]. Severe nutritional depletion was significantly associated only with a LOS > 12 d. CONCLUSION: Fat-free mass and fat-free-mass index were significantly lower in patients than in control subjects. Because the fat-free-mass index is significantly associated with an increased LOS, provides nutritional assessment information that complements that from a Subjective Global Assessment questionnaire, and is a more sensitive determinant of the association of fat-free mass with LOS than is a weight loss > 10% or a body mass index < 20, it should be used to evaluate nutritional status.
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Índice de Masa Corporal , Hospitalización , Tiempo de Internación , Desnutrición/metabolismo , Evaluación Nutricional , Tejido Adiposo , Anciano , Estudios de Casos y Controles , Impedancia Eléctrica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de RegresiónRESUMEN
BACKGROUND: To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year. PURPOSE: The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years. METHOD: Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships. RESULTS: On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit. CONCLUSIONS: To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.
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Curriculum , Educación de Pregrado en Medicina/métodos , Aprendizaje Basado en Problemas/métodos , Ciencia/educación , Prácticas Clínicas/normas , Competencia Clínica/normas , Humanos , Aprendizaje , Estudios Longitudinales , Solución de Problemas , Encuestas y Cuestionarios , SuizaRESUMEN
PURPOSE: To evaluate abdominal ultrasonography (US) for indirect (with free fluid analysis only) and direct (with free fluid and parenchymal analysis) detection of organ injury in patients with blunt abdominal trauma, with findings at computed tomography (CT) and/or surgery as the standard of diagnosis. MATERIALS AND METHODS: Abdominal US was performed at hospital admission in consecutive patients with blunt abdominal trauma. The presence of free peritoneal fluid and organ injury were recorded and compared with results of abdominal CT in all hemodynamically stable patients. When US results were considered false-negative for free fluid or organ injury compared with CT results, repeat US was performed within 6 hours. Admission and second US results were compared with CT and/or surgical results to determine sensitivity, specificity, negative predictive value, and positive predictive value of US with regard to the presence of free intraperitoneal fluid and/or organ injury. RESULTS: Two hundred five hemodynamically stable patients underwent abdominal US and CT. CT revealed free fluid in 83 patients and organ injury in 99. Thirty-one (31%) of 99 patients with organ injury did not have free fluid at CT. Three (10%) of the 31 patients required surgery or angiographic embolization. The sensitivity of admission US was 93% (77 of 83 cases) for the diagnosis of free fluid, 41% (39 of 99) for directly demonstrating organ injury, and 72% (71 of 99) for suggesting organ injury by means of both free fluid and organ analysis. At second US, these sensitivities were 96% (80 of 83 cases), 55% (54 of 99) and 84% (83 of 99), respectively. CONCLUSION: US is highly sensitive for the detection of free intraperitoneal fluid but not sensitive for the identification of organ injuries. In hemodynamically stable patients, the value of US is mainly limited by the large percentage of organ injuries that are not associated with free fluid.
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Traumatismos Abdominales/diagnóstico por imagen , Líquidos Corporales , Heridas no Penetrantes/diagnóstico por imagen , Adolescente , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Prospectivos , Sensibilidad y Especificidad , UltrasonografíaRESUMEN
Overcrowding of emergency departments (ED) is on increasing concern and results from (1) patients using ED as their primary source of care, (2) aging of the population, (3) poor coordination between home care services and primary care physicians. Two groups of patients can be targeted to reduce the use of ED services. First, selected patients with acute conditions can be included in home hospitalization programs. In these programs home care services deliver complex treatment to patients with acute conditions under the supervision of their physician. Strong links between home care agencies and primary care physicians are required for the success of these programs and may limit their diffusion in non integrated delivery systems of care. Second, patients with chronic diseases may benefit from disease management programs which have been shown to reduce hospitalizations and cost-saving.
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Atención Ambulatoria/organización & administración , Aglomeración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Manejo de la Enfermedad , Necesidades y Demandas de Servicios de Salud , Servicios de Atención de Salud a Domicilio/organización & administración , HumanosRESUMEN
Histological analysis, which is used to detect and diagnose most tissue alterations, requires an invasive biopsy procedure and a time-consuming tissue treatment, which limit its efficiency in providing rapid, cost-effective diagnosis and hinder the longitudinal study of tissue alteration. To address these limitations, we have developed a novel procedure, using the features of elastic-scattering spectroscopy, for a real-time, non-invasive analysis of tissues. We have tested whether this approach can detect in vivo changes in mouse skin induced by a single exposure to either complete Freund's adjuvant or 12-O-tetradecanoylphorbol-13-acetate, two drugs known to induce discrete alterations of epidermis and dermis, without obvious changes on the skin surface. Here we report that the evaluation of localized absorption and reduced scattering coefficients permitted the detection of changes in skin regions that showed histological alterations, but not in regions which failed to be modified by the drugs. Results show that the optical in vivo analysis of small regions has sufficient specificity and sensitivity to detect minimal alterations of superficial tissues. In view of the prominent involvement of mucosal alterations in most human diseases, including carcinomas, the method provides a useful complement to standard biopsy, notably for the in vivo screening of early in situ epithelial alterations.