Appropriate Evaluation Of Patients Research Articles

Incidence of audiologic or otolaryngologic evaluation in patients with external ear anomalies

PurposeThe relationship between specific external ear anomalies (EEA) and hearing loss has been previously described. However, there is no literature regarding the appropriate evaluation of patients with EEA by audiology or otolaryngology. The objective of this study was to determine the incidence of audiologic or otolaryngologic evaluation of patients with EEA. Materials and methodsA retrospective review of charts was conducted following approval from the institutional review board at Boston Medical Center. Charts of patients younger than 18 years old with EEA, identified using International Classification of Diseases (ICD)-9 codes 380–380.99, 744, and 744.4 and ICD-10 codes H61.90–92, Q16.0–16.9, Q17.0–17.9, Q18.0–18.2, from January 2012 to January 2019 were reviewed. Primary variables included incidence of audiologic and otolaryngologic evaluation, newborn hearing screen and audiometry results, and completion of surgical intervention. Binary logistic regressions were conducted for each group for diagnostic, procedural, and demographic characteristics. ResultsA total of 723 patients were diagnosed with EEA from January 2012 to January 2019. Of these patients, 327 (45.2 %) were evaluated by audiology and 327 (45.2 %) were evaluated by otolaryngology. Of the 364 patients who obtained audiograms, 63 (17.3 %) demonstrated hearing loss. Surgical procedures were performed on 119 (16.5 %) patients, with the most common procedure being excision of the EEA (n = 79, 66.4 %). A total of 468 patients had a documented newborn hearing screen. Failure of newborn hearing screen and presence of microtia were associated with increased otolaryngologic and audiologic evaluation. ConclusionsA majority of patients with EEAs do not obtain audiologic or otolaryngologic evaluation.

Does Previous Perianal Surgery for Benign Diseases Have an Impact on Timing of Hospital Admission in Patients with Colorectal Cancer?

Objective. Colorectal cancer (CRC) is one of the most common and fatal malignancies worldwide. Although the clinical presentation varies according to the location of the tumor, hematochezia, tenesmus, changes in the defecation habit, chronic constipation, abdominal pain, and distension are the most common findings of CRCs. We aimed to investigate whether patients with CRC who had a surgical history for benign anal disease have more negative tumoral features or not. Material and Methods. Two-hundred fifty two patients who underwent surgery for CRC between 2010 and 2016 at general surgery clinic in Ankara Numune Training and Research Hospital included in this study. Patients were classified into two groups; patients who had undergone surgery for benign perianal disease such as hemorrhoid, anal fissure, perianal abscess and fistulae (Group 1) and patients without past history for perianal surgery (Group 2). Results. A total of 252 CRC patients with a mean age of 64.2 years were included in the study. There were 95 (37.7%) females and 157 (62.3%) males. There were 25 (9.9%) patients who had surgical history for benign perianal disease. There were no statistically differences in tumor size, lymph node positivity, presence of distant metastasis, and tumor stage between the groups (p > 0.05). Conclusion. Although not statistically significant, CRC patients with a history of surgery for benign perianal disease had less lymphatic metastases and tumor size than those without prior perianal surgery. We think that this finding is important in that it indicates the importance of detailed and appropriate evaluation of patients with CRC.

Psychological Distress and Drug Provocation Test-Related Anxiety Levels of Pediatric Patients and Their Parents.

Background: Drug provocation tests (DPTs) are the gold standard for the diagnosis of drug hypersensitivity reaction (DHR). To the best of our knowledge, there is no previous study reporting DPT-related anxiety levels in children and their parents. This study aimed to determine the difference in pre- and post-DPT anxiety levels of parents and children who were informed of the possibility of another DHR during the DPT, and to evaluate the relationship between parental psychological distress and anxiety levels. Methods: The study included children who underwent DPT in our clinic between July 1, 2019, and February 29, 2020, and accompanying parents who consented to participate. Age-appropriate State-Trait Anxiety Inventory scales were used to assess levels of state and trait anxiety in the patients and parents. The Symptom Checklist-90-Revised (SCL-90-R) was used to screen for psychological symptoms in parents. Results: Data were collected from the parents of 69 children who underwent DPTs. The patients' median age was 7.28 (interquartile range: 4.52-10.06) and their parents' mean age was 35.28 ± 5.38 years. Anxiety-related data were collected from 21 pediatric patients. The children and parents had higher state anxiety scores before DPT compared to after DPT. There was a positive correlation between the parents' trait anxiety and pre-DPT state anxiety scores. In addition, parental pre-DPT state anxiety scores were positively correlated with SCL-90-R general severity index, somatization, anxiety, obsessive-compulsive, and depression subscale scores. Conclusion: The risk of allergic reaction in DPT may cause anxiety. A high level of parental anxiety before DPT, which gradually decreased after negative test results, was associated with history of drug-induced anaphylaxis in their children and high trait anxiety. Appropriate evaluation of patients and parents before DPT and providing detailed information may be important to reduce this anxiety.

Flexible Fixation Technique for Subtle Lisfranc Injuries

Background: Subtle Lisfranc injuries represent a primarily ligamentous Lisfranc complex injury involving the Lisfranc ligament and the medial and middle cuneiform ligaments. Static radiographic displacement or dynamic instability of the medial cuneiform and 2nd metatarsal typically warrants operative intervention to prevent chronic functional pain, allow for timely return-to-sport, and mitigate posttraumatic osteoarthritis. Flexible fixation techniques offer a unique solution to the issues seen with transarticular screws, plates, and arthrodesis for ligamentous Lisfranc injuries. Indications: We present the case of a 16-year-old female basketball player with a subtle Lisfranc injury sustained during practice. X-rays show isolated widening of the 1st and 2nd metatarsal bases and dynamic diastasis between the medial and middle cuneiforms. Magnetic resonance imaging (MRI) confirmed a rupture of the plantar Lisfranc ligament. After extensive discussion regarding treatment options, the patient and her family decided to proceed with surgical intervention using a suture anchor and button technique to restore stability to the Lisfranc ligament and intercuneiform complexes. Technique Description: A standardized dynamic examination under anesthesia identifies the extent of the injury. Exposure of the base of the 2nd metatarsal and medial cuneiform is performed. Reduction clamps are applied to restore the intercuneiform relationship and interval between the medial cuneiform and base of 2nd metatarsal. The suture anchor and button construct is placed using fluoroscopic guidance. A final dynamic examination is performed to confirm stability of the construct. Results: Biomechanical studies have shown that flexible fixation maintains physiologic motion about the Lisfranc articulations and has comparable stability to transarticular screws in cadaveric models of isolated Lisfranc ligament insufficiency. Clinical results are limited but demonstrate excellent postoperative functional outcome scores with very few fixation-related complications at 1 to 3 years. Discussion: Flexible fixation techniques for subtle Lisfranc injuries offer unique benefits to transarticular screws, plates, and arthrodesis. We highlight the appropriate evaluation of patients with a suspected subtle ligamentous Lisfranc injury, the surgical technique using a suture button and anchor construct, and review postoperative management and expected outcomes based on the present literature.

Frequency of ocular manifestations in multiple sclerosis patients admitted in tertiary care hospital in Saudi Arabia.

Multiple Sclerosis (MS) is one of the most destructive demyelinating diseases of the nervous system, and it manifests through broad involvement of the visual system. The present study was aimed to evaluate the frequency of ocular symptoms among MS patients admitted to the Kingdom Hospital in Saudi Arabia PATIENTS AND METHODS: This is a cross-sectional study aiming at investigating the prevalence of eye disease among MS patients referred to Hawtat Sudair Hospital, Zulfi General Hospital, Majmaah General Hospital, and Kingdom Hospital in Riyadh (Saudi Arabia) from January 2020 to December 2020. The sample size was made of 100 MS patients including 50 males and 50 females, all presented with eye disorders. The data were analyzed with SPSS 25, Chi-square test, and descriptive statistics. The examined patients included 100 patients with MS symptoms aged 35 years, ranging from 20 to 70 years. The results showed a considerable lack of sharpness of vision among patients (80%), and the rate of double vision was reported to be about 49% among them which was the most prevalent vision problem from the onset of the disease until the examination time. The achieved data from this study demonstrated that multiple sclerosis could cause eye diseases. Initial recognition of this syndrome provides the possibility of having an appropriate evaluation of patients to clinicians. Moreover, after the prevalence of MS, other ocular symptoms may occur consequently.

Practice gaps in the evaluation of systemic involvement in patients with cutaneous sarcoidosis presenting to a dermatologist: A retrospective review of 48 patients

Sarcoidosis is a systemic granulomatous disorder of unknown etiology with a variable prognosis. The skin is one of the organs most commonly affected, with up to 30% of cases involving the skin.1 Because the cutaneous manifestations of sarcoidosis often present at disease onset,1 a dermatologists may be the first physician to diagnose a patient with sarcoidosis. As such, dermatologists are often responsible for initiating the appropriate evaluation of patients with sarcoidosis.

Clinical recognition and evaluation of patients with inherited serum thyroid hormone-binding protein mutations.

There are three important thyroid hormone-binding proteins in human serum, thyroxine-binding globulin, transthyretin, and albumin. Genetic variation in these proteins can lead to altered thyroid hormone binding and abnormalities in serum tests of thyroid hormone. Importantly, patients harboring these mutations are euthyroid; thus, the recognition of these conditions is crucial to prevent unnecessary repeated testing and treatment. This article provides an updated overview of serum thyroid hormone transport biology and reviews the underlying genetic alterations, clinical presentation, and appropriate evaluation of patients with suspected mutations in serum thyroid hormone-binding proteins.

Managing Hot Flushes in Menopausal Women: A Review.

Hot flushes during menopause are distressing for women and result in poor quality of life. Purpose of the current review was to evaluate the available treatment modalities that should be utilised for the management of hot flushes. Menopause refers to last menses of women life and can be declared after amenorrhea of 12 months. Vasomotor symptoms including hot flushes and night sweats are common after menopause, affecting almost 50 - 85% women older than 45 years. The mean increment in core body and skin temperature is 0.5°C and 0.25 - 3°C during a hot flush attack. Low level of estrogen during menopause and its association in triggering episodes of hot flushes, is still under debate. The most accepted hypothesis is a narrowing of the thermoneutral zone (TNZ) triggered by estrogen fluctuations. Although, hormone replacement therapy (HRT) remains the standard treatment for the alleviation of such symptoms, incidence of life threatening side effects restrained medical professionals from its use. Complications associated with the use of HRT can be avoided by appropriate evaluation of patients before initiating therapy. Several guidelines have also recommended HRT (estrogen and progesterone) to be safe for up to a period of seven years. Both hormonal and non-hormonal treatments are used for the management of hot flushes. Since hot flushes are the least appreciated and neglected complication of menopause, current review provides detailed information on its background, pathophysiology and management, and emphasises the need of its treatment.

Comprehensive Quality Control of the Regenerative Therapy Using Platelet Concentrates: The Current Situation and Prospects in Japan.

Platelet concentrates (PCs), represented by platelet-rich plasma (PRP), have been widely applied in the fields of regenerative and aesthetic therapies. PCs' mechanisms of action, however, are too complicated, and it is not easy to present the whole picture; besides, clinical outcomes are hardly reproducible in many cases. Therefore, several medically advanced countries seemingly intend to regulate PC therapies weakly or strictly because of the increasing popularity. Japan established laws and regulations for PC therapy in the “Act on the Safety of Regenerative Medicine” along with the “Pharmaceuticals, Medical Devices and Other Therapeutic Products Act” in 2014, which, to our knowledge, represent the strictest regulatory framework for production and therapeutic use of PCs in the world. According to these laws and regulations, PCs produced for topical use should be prepared as cell-based medicinal products, essentially as should stem cells, in accordance with their registered (“licensed” under actual conditions) standard operating procedures. Nonetheless, criteria for their quality are not standardized. In this review, we discuss the quality of PC preparations by focusing on the basic concept and regulatory framework of regenerative medicine in Japan. Within the new framework, PC therapy is regulated by a specific notification and registration system, as is stem cell therapy. In comparison with the latter, however, risk factors that hamper successful PC therapy are much fewer. Via appropriate evaluation of patients' conditions and whole-blood samples by simple and sensitive but not yet fully standardized assays, it is theoretically possible that PC quality will be controlled nearly completely. In addition to or instead of standardization of preparation protocols, standardization of preoperative examination of individual PC preparations is an urgent task for improving and guaranteeing the safety and efficacy of PC therapy.

Tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome clinically characterized by bone pain, fractures and muscle weakness. It is caused by tumoral overproduction of fibroblast growth factor 23 (FGF23) that acts primarily at the proximal renal tubule, decreasing phosphate reabsorption and 1α-hydroxylation of 25 hydroxyvitamin D, thus producing hypophosphatemia and osteomalacia. Lesions are typically small, benign mesenchymal tumors that may be found in bone or soft tissue, anywhere in the body. In up to 60% of these tumors, a fibronectin-1(FN1) and fibroblast growth factor receptor-1 (FGFR1) fusion gene has been identified that may serve as a tumoral driver. The diagnosis is established by the finding of acquired chronic hypophosphatemia due to isolated renal phosphate wasting with concomitant elevated or inappropriately normal blood levels of FGF23 and decreased or inappropriately normal 1,25-OH2-Vitamin D (1,25(OH)2D). Locating the tumor is critical, as complete removal is curative. For this purpose, a step-wise approach is recommended, starting with a thorough medical history and physical examination, followed by functional imaging. Suspicious lesions should be confirmed by anatomical imaging, and if needed, selective venous sampling with measurement of FGF23. If the tumor is not localized, or surgical resection is not possible, medical therapy with phosphate and active vitamin D is usually successful in healing the osteomalacia and reducing symptoms. However, compliance is often poor due to the frequent dosing regimen and side effects. Furthermore, careful monitoring is needed to avoid complications such us secondary/tertiary hyperparathyroidism, hypercalciuria, and nephrocalcinosis. Novel therapeutical approaches are being developed for TIO patients, such as image-guided tumor ablation and medical treatment with the anti-FGF23 monoclonal antibody KRN23 or anti FGFR medications. The case of a patient with TIO is presented to illustrate the importance of adequate and appropriate evaluation of patients with bone pain and hypophosphatemia, as well as an step-wise localization study of patients with suspected TIO.

Nephrotic syndrome redux.

Redux: brought back, resurgent (Wikipedia free dictionary). This essay traces the history of the concepts that led to the usage of the term 'nephrotic syndrome' beginning ∼90 years ago. We then examined the various definitions used for this syndrome and modified them to conform to contemporary standards. Remarkably, only minor modifications were required. This analysis of a common clinical entity may be helpful in ensuring appropriate evaluation of patients suffering from nephrotic syndrome and nephrotic-range proteinuria.

Residual neuromuscular blockade and postoperative critical respiratory events: literature review

To investigate and synthesise published literature on the associations between residual neuromuscular blockade and critical respiratory events of postoperative adult patients in the postanaesthesia care unit. Residual neuromuscular blockade continues to be common among patients transferred to the postanaesthesia care unit after general anaesthesia, while negative effects of residual neuromuscular blockade on respiratory function have been demonstrated in laboratory volunteers. Literature review. Using key terms, a search was conducted in Cumulative Index for Nursing and Allied Health Literature, PubMed, Web of Science, Cochrane Database and EMBASE (January 1990-May 2013) for clinical trials or observational studies on the associations between residual neuromuscular blockade and critical respiratory events, published in English-language journals. Nine articles met the inclusion criteria. Residual neuromuscular blockade definition threshold differed between studies. Among critical respiratory events, only hypoxaemia was investigated in all included studies. Residual neuromuscular blockade was significantly associated with increased incidence of hypoxaemia during postanaesthesia care unit stay in most studies, while associations with the rest of the critical respiratory events were inconclusive. Although limited, existing research has provided evidence that patients with residual neuromuscular blockade are at high risk of early postoperative hypoxaemia. Further studies are needed to investigate independent associations between residual neuromuscular blockade and critical respiratory events, along with causality of these associations. The clinical importance of residual neuromuscular blockade for groups at high risk of critical respiratory events should also be investigated. Healthcare professionals have to be aware of the increased risk of hypoxaemia in patients with residual neuromuscular blockade. Efforts to decrease residual neuromuscular blockade incidence, combined with identification and appropriate evaluation of patients with residual neuromuscular blockade during postanaesthesia care unit stay, are recommended.

Evaluation of Patients with Microangiopathic Hemolytic Anemia and Thrombocytopenia

When a patient presents with unexpected microangiopathic hemolytic anemia and thrombocytopenia, the diagnosis of thrombotic thrombocytopenic purpura (TTP) is often considered. However, many different disorders, including many different systemic infections and malignancies, can cause thrombotic microangiopathy (TMA), with the clinical features of microangiopathic hemolytic anemia and thrombocytopenia. Other etiologies include severe hypertension, preeclampsia, systemic lupus erythematosus, adverse drug reactions, allogeneic hematopoietic stem cell transplantation, and abnormalities of complement regulation. This article focuses on distinguishing TTP from other etiologies of microangiopathic hemolytic anemia and thrombocytopenia, because consideration of the diagnosis of TTP requires an urgent decision for the initiation of plasma exchange treatment. Awareness of the many etiologies of TMA is essential for the appropriate evaluation of patients presenting with microangiopathic hemolytic anemia and thrombocytopenia and the appropriate diagnosis of TTP.

Chemotherapy and renal toxicity

Antineoplastic drugs used in the treatment of cancers present with variable renal tolerance profiles. Among drugs with a potential for renal toxicity, platinum salts, methotrexate, and gemcitabine are well-known. The mechanisms of their renal toxicity and the means of its prevention are presented in this article. Anti-angiogenic drugs, recently marketed or still under clinical development, may also interact with the kidneys. In general, optimising the renal tolerance of anticancer drugs requires an appropriate evaluation of patients'renal function, before and during treatment, at each course. Serum creatinine alone is not a reliable index of renal function. Its evaluation must be performed with the use of Cockcroft-Gault or aMDRD formulae. In patients with abnormal renal function, dosage adjustment is often required to improve the renal tolerance, and also to limit the risk of extra-renal toxicities (such as haematological toxicities) induced by a drug overdosage, in those patients with reduced drug-elimination.

Tratamento das dislipidemias: como e quando indicar a combinação de medicamentos hipolipemiantes

Familial combined hyperlipidemia (FCH) is a frequent familial lipid disorder associated with insulin resistance, low HDL cholesterol, high triglycerides and cholesterol levels with variable phenotypes within the same family. FCH is linked to a high risk for cardiovascular diseases. Treatment goals for lipid abnormalities are changing in recent years. Lowering elevated levels of LDL e Non HDL-cholesterol levels are primary targets of therapy. Lower LDL-C than 70 mg/dL seems to be useful to lower cardiovascular risk in patients with very high risk. Many statins are available, with different potencies and drug interactions. Combination therapy of statins and bile acid sequestrants or ezitimibe may be necessary to further decrease LDL cholesterol levels in order to meet guideline goals. High triglycerides and low HDL cholesterol are also important goals in the treatment of these patients, and frequently statins alone are insufficient to normalize the lipid profile. Combination therapy with fibrates will further lower triglycerides and increase HDL cholesterol levels; this combination is also associated with higher incidence of myopathy and liver toxicity; appropriate evaluation of patients' risk and benefits is necessary. Association of statin/niacin seems be very useful in patients with FCH, especially as niacin is the best drug to increase HDL cholesterol; this association is not linked to a higher frequency of myopathy. Niacin causes flushing, that can in part be managed with use of aspirin and extended release forms (Niaspan); niacin also may increase plasma glucose and uric acid levels. Evaluation of risks and benefits for each patient is needed.

Phosphodiesterase inhibitors in female sexual dysfunction

Based on the increasing knowledge on both the physiology of penile erection and the pathophysiology of erectile dysfunction, selective phosphodiesterase (PDE) inhibitors have been successfully introduced in the oral treatment of male erectile dysfunction. Because of their central role in smooth muscle tone regulation, PDEs remain an attractive target for drug development in urology. Since the distribution and functional significance of PDE isoenzymes vary in different tissues, selective inhibitors of the isoenzymes have the potential to exert at least partially specific effects on the target tissue. Currently, PDE inhibitors are under investigation with potential uses in urinary stone disease, overactive bladder and the so-called benign prostatic syndrome. The convincing clinical data on the use of the orally active PDE5 inhibitors sildenafil (VIAGRA), vardenafil (LEVITRA) and tadalafil (CIALIS) in the treatment of erectile dysfunction are accompanied by boosting research activities on intracellular signal transduction and PDE characterisation in female genital tissues with the aid of immunohistochemistry and immunocytochemistry and molecular biology. The expression of various PDE isoforms in the human clitoris, vagina and labia minora was shown by means of immunohistochemistry and RT-PCR analyses and it was concluded from functional studies that an increase in cGMP or cAMP might be involved in the regulation of female genital blood flow and the control of genital non-vascular smooth muscle. As a consequence, the efficacy and safety of the PDE5 inhibitor sildenafil in the treatment of symptoms of female sexual dysfunction (FSD), including female sexual arousal disorders (FSAD), have been evaluated. Although the experiences from these early clinical studies have so far not been conclusive, they suggest that, after appropriate evaluation of patients, inhibition of PDE5 might be of benefit for selected individuals with FSAD. Such research efforts will possibly allow the identification of efficacious and diagnostic tools for erectile dysfunction and of even more selective drugs in its therapy.

Diagnosis of food allergy

Food allergy is gaining substantial interest by both the public and health professionals. It is usually overdiagnosed by the public and misdiagnosed by physicians. To provide an outline for appropriate evaluation of patients suspected of having food allergy. Information was derived from selected review and original articles published in peer-reviewed journals and from authoritative textbook chapters, supplemented by the clinical experience of the author. Several approaches have been used for food allergy diagnosis, including the medical history, trials of elimination diets, food/symptom diary, skin testing, in vitro tests, and oral challenges. In most cases, the medical history is inconclusive and the reliability of the in vivo and in vitro tests is suboptimal. Appropriately designed challenge testing remains the gold standard, although it has a few limitations. Appropriate selection, application, and interpretation of tests for food allergy are necessary for attaining a high degree of accuracy of diagnosis.

SURGERY OF THE ADRENAL GLANDS

Because widespread use of imaging techniques has led to the frequent detection of incidentalomas, radiologists, endocrinologists, and endocrine surgeons must be knowledgeable about the appropriate evaluation of patients, and the selection of the appropriate surgical approach, including conventional open and laparoscopic adrenalectomy. This article reviews the authors' preferences based on experience with nearly 200 laparoscopic adrenalectomies.

Invited review: Peripheral neuropathy in Sjogren' syndrome

Our experience and review of the literature reveal that Sjogren's syndrome (SS) is an important, poorly recognized cause of peripheral neuropathy. Several forms of peripheral nerve dysfunction occur in SS including trigeminal sensory neuropathy, mononeuropathy multiplex, distal sensory neuropathy, distal sensorimotor peripheral neuropathy and a pure sensory neuronopathy syndrome. Rarely, chronic relapsing inflammatory polyneuropathy and multiple cranial neuropathies appear. Clinical evidence of glandular involvement is often minimal or absent when patients with SS develop peripheral neuropathy; and the diagnosis of the underlying condition is elusive. We review clinical and laboratory features of this disorder and suggest appropriate evaluation of patients with neuropathy and suspected SS.