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BMC Medical Education Dec 2023Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is...
BACKGROUND
Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is known about errors in specific fields of internal medicine such as endocrinology. This prospective, multicenter study focused on better understanding the causes of diagnostic errors made by general practitioners and internal specialists in the area of endocrinology.
METHODS
From August 2019 until January 2020, 24 physicians completed five endocrine cases on an online platform that simulated the diagnostic process. After each case, the participants had to state and explain why they chose their assumed diagnosis. The data gathering process as well as the participants' explanations were quantitatively and qualitatively analyzed to determine the causes of the errors. The diagnostic processes in correctly and incorrectly solved cases were compared.
RESULTS
Seven different causes of diagnostic error were identified, the most frequent being misidentification (mistaking one diagnosis with a related one or with more frequent and similar diseases) in 23% of the cases. Other causes were faulty context generation (21%) and premature closure (17%). The diagnostic confidence did not differ between correctly and incorrectly solved cases (median 8 out of 10, p = 0.24). However, in incorrectly solved cases, physicians spent less time on the technical findings (such as lab results, imaging) (median 250 s versus 199 s, p < 0.049).
CONCLUSIONS
The causes for errors in endocrine case scenarios are similar to the causes in other fields of internal medicine. Spending more time on technical findings might prevent misdiagnoses in everyday clinical practice.
Topics: Humans; Prospective Studies; Diagnostic Errors; Endocrinology; Internal Medicine; General Practitioners
PubMed: 38066602
DOI: 10.1186/s12909-023-04927-5 -
American Journal of Obstetrics and... May 2024Transabdominal cerclage is an effective surgical intervention for preterm birth prevention. Placement of cervical sutures using a port closure device for prepregnancy...
Transabdominal cerclage is an effective surgical intervention for preterm birth prevention. Placement of cervical sutures using a port closure device for prepregnancy laparoscopic abdominal cerclage has been used at our unit in recent years. We report the operative and pregnancy outcomes for prepregnancy laparoscopic abdominal cerclage using the port closure device and compare it with the outcomes of the traditional approach. For prepregnancy laparoscopic transabdominal cerclage (n=52), the port closure device approach was associated with less blood loss during surgery (0.95±4.4 mL vs 5.4±15.7 mL; P=.007) and a shorter hospital length of stay (0.0; 0.0-0.0 days vs 1.0; 0.0-1.0 days; P<.001). There were also trends toward shorter operating times (41.4±15.3 minutes vs 50.1±18.0 minutes; P=.167) and lower perioperative complication rates (0.0%; 0/21 vs 16.1%; 5/31; P=.065) when compared with the traditional technique. There was no significant difference between the port closure device technique and the traditional approach in the rate of preterm birth in a subsequent pregnancy (0.0%; 0/9 vs 22.6%; 7/39; P=.248). Use of the port closure device for suture placement during prepregnancy laparoscopic cerclage for preterm birth prevention was reported. This technique was associated with less blood loss and a shorter hospital length of stay, had trends toward shorter operating times and lower perioperative complication rates, and had similar rates of preterm birth.
Topics: Humans; Female; Pregnancy; Cerclage, Cervical; Laparoscopy; Adult; Suture Techniques; Pregnancy Outcome; Premature Birth; Length of Stay; Blood Loss, Surgical; Uterine Cervical Incompetence; Operative Time; Retrospective Studies
PubMed: 38065377
DOI: 10.1016/j.ajog.2023.12.002 -
Pediatric Surgery International Dec 2023To review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis...
AIM
To review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis (PPV), and comparison of complication rates between pre-term (< 37 week gestation) and term infants.
METHODS
Retrospective review of LIHR performed between 2009 and 2021. Repair was performed by intracorporal single or double purse string/purse string + Z-stitch using a non-absorbable suture. Data were analyzed using Chi-squared/Mann-Whitney and are quoted as median (range).
RESULTS
1855 inguinal rings were closed in 1195 patients (943 (79%) male). 1378 rings (74%) were symptomatic. 492 (41%) patients were pre-term. Corrected gestational age at surgery was 55 weeks (31 weeks-14.6 years) and weight 5.9 kg (1-65.5). Closure of contralateral PPV was higher in the premature group (210/397 [53%] vs. 265/613 [43%] p = 0.003). There were 23 recurrences in 20 patients, of whom 10 had been born prematurely. The only factor significantly associated with a lower recurrence was use of a second stitch (p = 0.011).
CONCLUSION
This is the largest single-center reported series of LIHR. LIHR is safe at any age, the risk of recurrence is low, and can be corrected by re-laparoscopy. Use of a Z-stitch or second purse string is associated with a significantly lower rate of recurrence.
Topics: Infant; Female; Humans; Male; Hernia, Inguinal; Treatment Outcome; Herniorrhaphy; Recurrence; Laparoscopy; Testicular Hydrocele; Retrospective Studies
PubMed: 38063992
DOI: 10.1007/s00383-023-05599-4 -
Cureus Nov 2023Diagnosis bias in the medical field is a recognized entity that can contribute to misdiagnoses and incorrect management. It remains a constant challenge that must be...
Diagnosis bias in the medical field is a recognized entity that can contribute to misdiagnoses and incorrect management. It remains a constant challenge that must be recognized and addressed. Several factors play a role in the formation of preconceptions which influence the physicians' decision-making process. The aim of this paper is to present a case that was misdiagnosed and mistakenly managed due to diagnosis bias during the coronavirus disease 2019 (COVID-19) pandemic. We also suggest two ways to reduce the risk of diagnosis bias. Multi-inflammatory syndrome of children (MIS-C) was described during the COVID-19 pandemic. The rise in the incidence of MIS-C masked the diagnosis of other diseases that present in a similar fashion. In this paper, we describe the case of a seven-year-old girl, who presented in 2020, with acute onset respiratory distress. Her chest images were suggestive of COVID-19 pneumonitis which prompted the physicians to complete the MIS-C workup by performing an echocardiogram. A large aneurysm of the left main artery was seen which led to a preliminary diagnosis of MIS-C. A repeat echocardiography, 48 hours after the initiation of MIS-C treatment, was suggestive of a large coronary fistula complicated by infective endocarditis and multiple septic pulmonary emboli. It can be inferred that the misdiagnosis occurred as a result of availability and premature-closure biases. Efforts to decrease such biases include group decision-making and using checklists during the assessment of a patient.
PubMed: 38058327
DOI: 10.7759/cureus.48282 -
Cureus Oct 2023Sagittal suture synostosis (SSS), caused by premature closure of the sagittal suture of the skull, is usually diagnosed and treated in the first few months of life;...
Sagittal suture synostosis (SSS), caused by premature closure of the sagittal suture of the skull, is usually diagnosed and treated in the first few months of life; delayed diagnosis can be associated with abnormalities in brain development, including raised intracranial pressure (ICP) and neurocognitive development impairments. It can also affect an individual's self-perception and self-esteem. We present a unique case of late presentation and treatment of non-syndromic sagittal synostosis in a 10-year-old. Whilst the patient and his family's main concerns were aesthetic, he also had neurobehavioural issues and needed glasses for vision. Total cranial vault remodelling was offered and successfully performed at the age of 10; this normalised his cephalic index, immediately improved vision, prevented the progression of neurobehavioural under-development and significantly improved self-esteem. This case highlights the difficulties of sagittal synostosis diagnosis, the potential consequences of delayed presentation and the success of treatment, even in an older age group.
PubMed: 38022196
DOI: 10.7759/cureus.47178 -
Cureus Oct 2023Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force... (Review)
Review
Acute patellar dislocation (PD) is usually a problem of adolescents and young adults. In most cases, it is a sports-related injury. It is the result of an indirect force on the knee joint, which leads to valgus and external rotation of the tibia relative to the femur. PD is unlikely to occur on a knee with normal patellofemoral joint (PFJ) anatomy. Acute PD consists of an acute injury of the ligamentous medial patellar stabilizers in the background of factors predisposing to patellar instability. These factors are classified into three groups. The first group refers to the integrity of the ligamentous medial patellar restraints, particularly, the medial patellofemoral ligament (MPFL). The second group refers to an abnormal PFJ anatomy, which renders the patella inherently unstable inside the trochlea. The third group refers to the overall axial and torsional profile of the lower limb and to systemic factors, such as ligament laxity and neuromuscular coordination of movement. PD at a younger age is associated with an increased number and severity of patellar instability predisposing factors and lower stress to dislocate the patella. Acute primary PD is usually treated conservatively, while surgical treatment is reserved for recurrent PD. The aim of treatment is to restore the stability and function of the PFJ and to reduce the risk of patellar redislocation. Surgical procedures to treat patellar instability are classified into non-anatomic and anatomic procedures. Non-anatomic procedures are extensor mechanism realignment techniques that aim to center the patella into the trochlear groove. Anatomic procedures aim to restore the PFJ anatomy (ruptured ligaments, osteochondral fractures), which has been severed after the first incident of PD. Anatomic procedures, especially MPFL reconstruction, are more effective in preventing recurrent PD, compared with non-anatomic techniques. Theoretically, all factors that affect PFJ stability should be evaluated and, if possible, addressed. This is practically impossible. Considering that the MPFL ruptures in almost all PDs, MPFL reconstruction is the primary procedure, which is currently selected by most surgeons as a first-line treatment for patients with recurrent PD. Restoration of the axial and torsional alignment of the lower limbs is also increasingly implemented by surgeons. Non-anatomic surgical techniques, such as tibial-tuberosity osteotomy, are used as an adjunct to anatomic procedures. In the presence of multiple PFJ instability factors, acute MPFL reconstruction may be the treatment of choice for acute primary PD as well. Skeletal immaturity of the patient precludes osseous procedures to avoid premature physis closure and subsequent limb deformity. Unfortunately, restoration of the patient's previous activity level or participation in more strenuous sports is questionable and not easy to predict. In the case of competitive athletes, PD may prevent participation in elite levels of sports.
PubMed: 38021800
DOI: 10.7759/cureus.46743 -
Cureus Oct 2023Sarcoidosis is a systemic inflammatory disease that can cause granulomatous infiltration of almost all organs and tissues which allows for a wide variety of...
Sarcoidosis is a systemic inflammatory disease that can cause granulomatous infiltration of almost all organs and tissues which allows for a wide variety of presentations that may overlap with other disease processes. Renal sarcoidosis is a much rarer site of extrapulmonary involvement and may present as hypercalcemia, tubular or glomerular dysfunction, and/or granulomatous interstitial nephritis. Prompt diagnosis of sarcoidosis is crucial for initiating appropriate treatment and avoiding organ dysfunction. Herein, we describe a case of an armed forces service member who developed extrapulmonary sarcoidosis and renal sarcoidosis with acute complications refractory to glucocorticoids requiring adalimumab. The case highlights and emphasizes a rare manifestation of extrapulmonary sarcoidosis, the importance of avoiding premature closure of the differential diagnosis to avoid diagnostic delay and treatment imitation, and the unique clinical reasoning that occurs in active-duty personnel where diagnoses and subsequent treatments can have career implications and affect the ability of the service member to maintain the ability to deploy worldwide.
PubMed: 38021643
DOI: 10.7759/cureus.47115 -
European Archives of... Feb 2024Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently...
PURPOSE
Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently understood. The aim of this study was to test a novel measurement device to measure breathing and pharyngeal processes involved in swallowing externally in everyday life to identify possible differences in neonates (NB) and PI.
METHODS
Forty healthy NB were studied at 4-8 weeks of age (mean: 6.7 weeks) and 20 healthy PI (mean gestational age 30.5 weeks) at postmenstrual age (PMA) 34/35 weeks (mean PMA 35.1 weeks) during a single feeding. Surface electrodes were used to measure bioimpedance and electromyography reflecting swallow-related changes in the pharynx and muscle activation of the tongue and submental muscles. A respiratory belt was combined with recording of the depth of chest movements and the occurrence of pauses in breathing.
RESULTS
Velocity and extent of pharyngeal closure did not differ significantly across the feeding period (velocity: p=0.09, closure: p=0.17), but during the first two suck-swallow bursts PI had greater velocity (p<0.001*) and extent of pharyngeal closure (p=0.004*) than NB. The duration of swallowing phases was significantly longer in PIs (p<0.001*), their muscle activation decreased faster (p<0.001*), and they had more pauses in breathing than NBs.
CONCLUSIONS
The novel measurement device allowed, for the first time in everyday life, the measurement of factors influencing swallowing and breath-swallow coordination in NBs and PIs. PIs showed differences from NBs most likely due to differences in muscle strength and condition.
Topics: Infant; Infant, Newborn; Humans; Deglutition; Infant, Premature; Electromyography; Sucking Behavior; Gestational Age
PubMed: 37996534
DOI: 10.1007/s00405-023-08344-8 -
Italian Journal of Pediatrics Nov 2023Ductal patency of preterm infants is potentially associated with long term morbidities related to either pulmonary overflow or systemic steal. When an interventional... (Review)
Review
Ductal patency of preterm infants is potentially associated with long term morbidities related to either pulmonary overflow or systemic steal. When an interventional closure is needed, it can be achieved with either surgical ligation or a catheter-based approach.Transcatheter PDA closure is among the safest of interventional cardiac procedures and it is the first choice for ductal closure in adults, children, and infants weighing more than 6 kg. In preterm and very low birth weight infants, it is increasingly becoming a valid and safe alternative to ligation, especially for the high success rate and the minor invasiveness and side effects. Nevertheless, being it performed at increasingly lower weights and gestational ages, hemodynamic complications are possible events to be foreseen.Procedural steps, timing, results, possible complications and available monitoring systems, as well as future outlooks are here discussed.
Topics: Infant; Child; Infant, Newborn; Humans; Infant, Premature; Ductus Arteriosus, Patent; Hemodynamic Monitoring; Feasibility Studies; Gestational Age; Treatment Outcome
PubMed: 37932790
DOI: 10.1186/s13052-023-01552-2 -
Zhongguo Dang Dai Er Ke Za Zhi =... Oct 2023To investigate the risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants.
OBJECTIVES
To investigate the risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants.
METHODS
A retrospective analysis was conducted on clinical data of extremely preterm infants admitted to the Children's Hospital of Zhejiang University School of Medicine from January 2019 to April 2022. Based on the presence of hypotension within 72 hours after birth, the eligible infants were divided into a hypotension group (41 cases) and a normotension group (82 cases). The clinical characteristics, echocardiographic parameters within 72 hours after birth, and early complications were compared between the two groups. Multivariate logistic regression analysis was used to explore the risk factors for hypotension within 72 hours after birth, and receiver operating characteristic curve analysis was performed to evaluate the predictive value of relevant indicators for the occurrence of hypotension within 72 hours after birth in the preterm infants.
RESULTS
The proportion of infants who required medication or surgical closure of patent ductus arteriosus (PDA), the proportions of infants with intraventricular hemorrhage ≥ grade III and severe pulmonary hemorrhage, and the mortality rate within 7 days in the hypotension group were significantly higher than those in the normotension group (<0.05). Multivariate logistic regression analysis showed that lower birth weight, larger PDA diameter, and hemodynamically significant PDA were risk factors for the occurrence of hypotension within 72 hours after birth in extremely preterm infants (<0.05). The receiver operating characteristic curve analysis showed that the combination of birth weight, PDA diameter, and hemodynamically significant PDA had an area under the curve of 0.873 (95%: 0.802-0.944, <0.05) for predicting hypotension within 72 hours after birth, with a sensitivity of 73.2% and specificity of 91.5%.
CONCLUSIONS
Hypotension within 72 hours after birth is closely related to birth weight and PDA, and increases the risk of early severe complications and mortality in extremely preterm infants.
Topics: Child; Infant, Newborn; Humans; Infant, Extremely Premature; Birth Weight; Retrospective Studies; Ductus Arteriosus, Patent; Cerebral Hemorrhage; Prognosis; Hypotension; Risk Factors
PubMed: 37905755
DOI: 10.7499/j.issn.1008-8830.2304027