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Diagnosis (Berlin, Germany) Sep 2017For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission... (Review)
Review
For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission - i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission - i.e. the physician failed to do something right: almost always, failed to make a diagnosis. The number of malpractice lawsuits increased at a geometric rate beginning in the 1960s, and in the 1970s physicians began practicing defensive medicine, which lead physicians to order unnecessary radiology exams and tests. In the past 20 years the number of malpractice lawsuits has been decreasing, but the practice of defensive medicine has continued. Unnecessary exams and tests increase the likelihood of overdiagnosis and overtreatment, i.e. a new kind of error of commission.
Topics: Defensive Medicine; History, 19th Century; History, 20th Century; Humans; Malpractice; Medical Errors; Radiology
PubMed: 29536927
DOI: 10.1515/dx-2017-0007 -
BMJ (Clinical Research Ed.) Oct 2022To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by... (Randomized Controlled Trial)
Randomized Controlled Trial
Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial.
OBJECTIVE
To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease.
DESIGN
Prospective, multicentre, randomised pragmatic trial.
SETTING
Hospitals at 26 sites in 16 European countries.
PARTICIPANTS
2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%.
INTERVENTION
Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group.
MAIN OUTCOME MEASURES
The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications.
RESULTS
Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46).
CONCLUSION
This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men.
TRIAL REGISTRATION
NCT02400229ClinicalTrials.gov NCT02400229.
Topics: Female; Humans; Male; Coronary Angiography; Coronary Artery Disease; Prospective Studies; Chest Pain; Tomography, X-Ray Computed; Myocardial Infarction; Stroke; Computed Tomography Angiography; Predictive Value of Tests
PubMed: 36261169
DOI: 10.1136/bmj-2022-071133 -
Clinical Drug Investigation Apr 2021Second-generation antipsychotics (SGAs) for schizophrenia show different risk profiles, whose evidence has been evaluated through comparative reviews on randomized... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Second-generation antipsychotics (SGAs) for schizophrenia show different risk profiles, whose evidence has been evaluated through comparative reviews on randomized controlled trials (RCTs) and observational studies.
METHODS
We performed a systematic review and meta-analysis of weight gains, metabolic and cardiovascular side effects of SGAs, relying on both RCTs and observational studies, by comparing variations between the start of treatment and the end of follow-up. The systematic review refers to papers published from June 2009 to November 2020. PRISMA criteria were followed. No restrictions on heterogeneity level have been considered for meta-analysis. A test for the summary effect measure and heterogeneity (I metric) was used.
RESULTS
Seventy-nine papers were selected from 3076 studies (61% RCTs, 39% observational studies). Olanzapine and risperidone reported the greatest weight gain and olanzapine the largest BMI increase. Paliperidone showed the highest increase in total cholesterol, but is the only drug reporting an increase in the HDL cholesterol. Quetiapine XR showed the highest decrease in fasting glucose. Lurasidone showed the lowest increase in body weight and a reduction in BMI and was also the only treatment reporting a decrease in total cholesterol and triglycerides. The highest increase in systolic and diastolic blood pressure was reported by quetiapine XR.
CONCLUSIONS
Despite some limitations (differences in the mean dosages per patient and other side effects not included) this paper provides the first complete meta-analysis on SGAs in variations on metabolic risk profile between start of treatment and end of follow-up, with useful results for clinical practice and possibly for future economic evaluation studies.
Topics: Antipsychotic Agents; Humans; Randomized Controlled Trials as Topic; Schizophrenia; Weight Gain
PubMed: 33686614
DOI: 10.1007/s40261-021-01000-1 -
JAMA Cardiology Feb 2018Coronary computed tomographic angiography (coronary CTA) can characterize coronary artery disease, including high-risk plaque. A noninvasive method of identifying... (Randomized Controlled Trial)
Randomized Controlled Trial
Use of High-Risk Coronary Atherosclerotic Plaque Detection for Risk Stratification of Patients With Stable Chest Pain: A Secondary Analysis of the PROMISE Randomized Clinical Trial.
IMPORTANCE
Coronary computed tomographic angiography (coronary CTA) can characterize coronary artery disease, including high-risk plaque. A noninvasive method of identifying high-risk plaque before major adverse cardiovascular events (MACE) could provide practice-changing optimizations in coronary artery disease care.
OBJECTIVE
To determine whether high-risk plaque detected by coronary CTA was associated with incident MACE independently of significant stenosis (SS) and cardiovascular risk factors.
DESIGN, SETTING, AND PARTICIPANTS
This prespecified nested observational cohort study was part of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. All stable, symptomatic outpatients in this trial who required noninvasive cardiovascular testing and received coronary CTA were included and followed up for a median of 25 months.
EXPOSURES
Core laboratory assessment of coronary CTA for SS and high-risk plaque (eg, positive remodeling, low computed tomographic attenuation, or napkin-ring sign).
MAIN OUTCOMES AND MEASURES
The primary end point was an adjudicated composite of MACE (defined as death, myocardial infarction, or unstable angina).
RESULTS
The study included 4415 patients, of whom 2296 (52%) were women, with a mean age of 60.5 years, a median atherosclerotic cardiovascular disease (ASCVD) risk score of 11, and a MACE rate of 3% (131 events). A total of 676 patients (15.3%) had high-risk plaques, and 276 (6.3%) had SS. The presence of high-risk plaque was associated with a higher MACE rate (6.4% vs 2.4%; hazard ratio, 2.73; 95% CI, 1.89-3.93). This association persisted after adjustment for ASCVD risk score and SS (adjusted hazard ratio [aHR], 1.72; 95% CI, 1.13-2.62). Adding high-risk plaque to the ASCVD risk score and SS assessment led to a significant continuous net reclassification improvement (0.34; 95% CI, 0.02-0.51). Presence of high-risk plaque increased MACE risk among patients with nonobstructive coronary artery disease relative to patients without high-risk plaque (aHR, 4.31 vs 2.64; 95% CI, 2.25-8.26 vs 1.49-4.69). There were no significant differences in MACE in patients with SS and high-risk plaque as opposed to those with SS but not high-risk plaque (aHR, 8.68 vs. 9.31; 95% CI, 4.25-17.73 vs 4.21-20.61). High-risk plaque was a stronger predictor of MACE in women (aHR, 2.41; 95% CI, 1.25-4.64) vs men (aHR, 1.40; 95% CI, 0.81-2.39) and younger patients (aHR, 2.33; 95% CI, 1.20-4.51) vs older ones (aHR, 1.36; 95% CI, 0.77-2.39).
CONCLUSIONS AND RELEVANCE
High-risk plaque found by coronary CTA was associated with a future MACE in a large US population of outpatients with stable chest pain. High-risk plaque may be an additional risk stratification tool, especially in patients with nonobstructive coronary artery disease, younger patients, and women. The importance of findings is limited by low absolute MACE rates and low positive predictive value of high-risk plaque.
TRIAL REGISTRATION
clinicaltrials.gov Indentifier: NCT01174550.
Topics: Chest Pain; Computed Tomography Angiography; Coronary Angiography; Coronary Stenosis; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Plaque, Atherosclerotic; Prognosis; Risk Assessment; Ventricular Remodeling
PubMed: 29322167
DOI: 10.1001/jamacardio.2017.4973 -
Research in Microbiology 2020
Topics: Bacteria; Bacterial Proteins; Biological Transport; Carrier Proteins; Metals
PubMed: 31811938
DOI: 10.1016/j.resmic.2019.11.003 -
AJNR. American Journal of Neuroradiology Dec 2015In April 2015, the American Roentgen Ray Society and the American Society of Neuroradiology cosponsored a unique program designed to evaluate the state of the art in the... (Review)
Review
In April 2015, the American Roentgen Ray Society and the American Society of Neuroradiology cosponsored a unique program designed to evaluate the state of the art in the imaging work-up of acute stroke. This topic has grown in importance because of the recent randomized controlled trials demonstrating the clear efficacy of endovascular stroke treatment. The authors, who were participants in that symposium, will highlight the points of emphasis in this article.
Topics: Embolectomy; Endovascular Procedures; Humans; Multimodal Imaging; Stroke; Thrombolytic Therapy
PubMed: 26427831
DOI: 10.3174/ajnr.A4530 -
Therapeutic Advances in Gastroenterology 2020Upper gastrointestinal (UGI) endoscopy contributes a major clinical service with consistently growing demand around the world. Its utility corresponds to varying... (Review)
Review
Upper gastrointestinal (UGI) endoscopy contributes a major clinical service with consistently growing demand around the world. Its utility corresponds to varying epidemiological issues throughout the globe, with cancer screening and surveillance being of the utmost priority. Despite high accuracy in neoplasia detection, UGI endoscopy remains a highly operator-dependent procedure, characterized by a substantial rate of missed pathology. Despite an overall lack of high-quality performance measures, there is an increased level of awareness about the need for quality control of this procedure, which is reflected in several guidelines and position statements published in recent years. It is widely recognized that quality assessment should go beyond mere technical aspects of the examination, and include both pre- and post-procedural factors. By this means, quality control encompasses the entire patient experience with the health care provider, from appropriate indication and physical assessment, through high-quality endoscopy service, to appropriate follow up and patient satisfaction. This article aims to review the available and emerging quality metrics for UGI endoscopy, taken mostly from Western endoscopy societies, with references to Asian recommendations where appropriate. The paper is limited solely to diagnostic UGI endoscopy and does not include performance measures for therapeutic procedures.
PubMed: 32477426
DOI: 10.1177/1756284820916693