Initial Complaint Research Articles

Clinical and therapeutic profile of patients who are victims of non-traumatic subarachnoid hemorrhage in the unified health system in the municipality of Barbacena - MG

Introduction: The non-traumatic subarachnoid hemorrhage (HSANT) remains with unchanged incidence rates, in contrast to the reduction in the occurrence of other cerebrovascular disorders. It shows high morbidity and mortality and causes disability in young people. Objective: to evaluate the clinical characteristics and treatment of non-traumatic HSA victims. Method: cross-sectional and descriptive study of 91 medical records from victims of non-traumatic HSA undergoing cerebral angiography in the Unified Health System (SUS) in Barbacena, between 2006 and 2010. Result: 55.0% of HSANT occurred in women; 48.3% between 31 and 50 years of age, with an average of 47 years old; explosive headache was the initial complaint in 84.6%; 71.2% hypertense and 65.9% due to aneurysm. Hydrocephalus was developed in 100% of patients undergoing surgery after the 16 th day after surgery; 100% of those infected remained hospitalized for more than six days. Conclusion: HSANT predominates in women between 31 and 50 years of age, having the explosive headache as the main complaint and aneurysmal disease as the main etiology. Hypertension was the major risk factor. The risk of infection is higher in patients admitted for more than six days, and the development of hydrocephalus seems to be associated with late surgical treatment.

Metastatic Seminoma Presenting as Enlarging Retroperitoneal Mass in a Patient with Neurofibromatosis I

Neurofibromatosis type 1 (NF1) is a rare genetic disorder where patients develop neurofibromas and have characteristic skin and eye findings. These patients have increased risks for certain types of cancers, especially of neural origin. Testicular cancer is a relatively common type of cancer for younger men, and is considered a very treatable malignancy if identified early. This report describes a patient with NF1 who had an initial chief complaint of back pain. A retroperitoneal mass was identified, but initial pathology report was epithelioid granulomas without necrosis, and was non-diagnostic. After the patient developed deep vein thrombosis as complication of the mass, a repeat biopsy would provide the diagnosis of typical seminoma. A second review by independent pathologists of the primary biopsy sample was also unable to appropriately diagnose the seminoma. This report illustrates how a clear pathological diagnosis can drastically alter the approach to the disease and change the prognosis in a patient with an already rare disorder.

A Study of Methadone-Poisoned Children Referred to Hamadan's Besat Hospital/Iran.

Increasing use of methadone in withdrawal programs has increased methadone poisoning in children. This research aimed to study the causes of incidence of poisoning in children and its side-effects. In this research, The hospital records of all methadone-poisoned children referred to Hamadan's Be'sat Hospital from June 2007 to March 2013, were studied. Children with a definite history of methadone use or proven existence of methadone in their urine, were studied. During 5 years, 62 children with the mean age of 53.24±29.50 months were hospitalized due to methadone use. There was a significant relationship between delayed referral to hospital and increased bradypnea. According to their history, 25.8% and 58.1% of the children had been poisoned by methadone tablet and syrup, respectively. The most common initial complaint expressed by parents, was decreased consciousness (85.5%). During the initial examination, decreased consciousness, meiosis, and respiratory depression were observed in 91.9%, 82.3%, and 69.4% of the cases, respectively. Nine patients required mechanical ventilation. There was a significant relationship between the need for mechanical ventilation and seizure with initial symptom of emesis. There were two cases of death (3.2%), both of which were secondary to prolonged hypoxia and brain death. There was a significant relationship between poor patient prognosis (death) and presence of cyanosis in early symptoms, seizure, hypotension, duration of decreased consciousness, and duration of mechanical ventilation. This research indicated that the occurrence of seizure, hypotension, and cyanosis in the early stages of poisoning is associated with an increased risk of side effects and death and are serious warning signs. Early diagnosis and intervention can improve outcomes of methadone-poisoned children.

Traditional Medicine Information Management

Objective: Given the increasing development of traditional medicine, the World Health Organization (WHO) has noted data management of traditional medicine and the need for acquiring the existing knowledge through the accurate exchange of information as well as preservation and protection of traditional knowledge resources. The use of traditional medicine in developing countries and developed countries is increasingly expanding. The purpose of this study is to developa traditional medicine information management processing. Methods: This is a review article which is carried out using books, articles, national and international journals as well as electronic resources and websites available on the Internet. Results: Despite the increasing development of traditional medicine, information has not been developed. Information development through web-based resources, proper communication with physicians and pharmaceutical packaging can lead to the development of information and quality of care. WHO has become a convenient and reliable source for information exchange. A global database of traditional medicine as well as a global database of medicinal herbs has been developed by WHO. The recommendations of WHO on documentation of traditional medicine include initial complaint recording, medical history, the findings of the physical examination, examination diagnosis and treatment plan, privacy and patient satisfaction, insurance and legal reports. Data elements should be standardized for comparison. The data can be transferred using electronic records. Furthermore, the record of data and assessment of patient’s status will be done better. WHO published the international standard terminology that is the underlying data to better understanding of actions, research and training and developing a database to retrieve articles. The chapter 23 of the book, ICD 11, is developed tomake evidence-based traditional medicine, terminology, diagnosis classification, and designed interventions. It is also widely used in the International Classification of Traditional Medicine (ICTM) project which employs a wide range of traditional medicine knowledge worldwide. Conclusion: Given the development of traditional medicine, therapeutic interventions and medicinal complications of traditional and conventional medicine cause risks to patients. Development of reliable information and proper communication of patients and physicians will be helpful. Standard documentation, the global database and international classification and naming resources will integrate information and develop global statistics. Information development and information management process have an important role in improvement of patient care.

Neuropsychological syndromes in multiple sclerosis.

Cognitive impairment in multiple sclerosis (MS) is common (45-65%).Deficits occur in speed of information processing (SIP), memory, attention, executive functions (EF) and visuoconstruction.Involvement of cognitive functions like language and gnosis is rare and lesser known. Our aim is to describe the cognitive function and the clinical and radiological features of five patients with MS and with neuropsychological syndromes (NPS). Retrospective review of MS patients with NPS studied, using specific tests of SIP, memory, attention, EF, visuo-spatial abilities, praxis and language. The sample included four women (3 relapsing-remitting MS/1 secondary progressive MS) and one man with primary progressive MS (aged between 30-55 years). Cognitive symptoms were the initial complaint in three cases. Three cases presented apperceptive agnosia and constructive apraxia, one case presented alexia with agraphia and the fifth patient presented motor aphasia. Four patients suffered cognitive dysfunction considered typical of MS. Magnetic resonance imaging (MR) in all cases showed high lesion volumes in T1 and T2-weighted sequences. A good correlation was observed between cognitive deficits and the location of the lesions in four patients. NPS may be the initial complaint in MS patients, often associated with other cognitive deficits, and it shows a close relationship with lesion location.

A Pre- and Postoperative Evaluation of Multiple Joint Involvement as the Initial Finding of Cervical Syringomyelia and Neuropathic Arthropathy

Syringomyelia is a progressive, degenerative disorder, in which a longitudinal cyst forms within the spinal cord. Neuropathic arthropathy can be seen in the late phases of the disease, with the most frequent involvement being in the shoulder. Herein, we present a 42-year-old female case who was diagnosed with syringomyelia as well as Arnold-Chiari Syndrome and neuropathic arthropathy. Her initial complaints were painless edema in the right shoulder and elbow, wounds on the tips of her fingers and amputations. She was evaluated both pre- and postoperative periods. It should be kept in mind that neuropathic arthropathy may develop as the initial symptom in spinal cord lesions which progress slowly.

A Complex Rhythm Treated Simply: Fascicular Ventricular Tachycardia

A patient with no known history of ischemic or structural heart disease developed a ventricular tachyarrhythmia from a somewhat uncommon cause. The 57-year-old man presented to the emergency department with an initial complaint of several days of abdominal pain. During examination, he was found to have an irregular rapid heart rate. A 12-lead electrocardiogram (ECG) revealed a wide-complex tachycardia at a rate of 186 beats per minute (Figure 1A) with 2:1 ventriculoatrial conduction (Figure 2). The patient denied any active or prior chest pain, palpitations, presyncope, or syncope. Figure 2This magnified section of Figure 1 concentrates on leads II, III, and V1 and demonstrates 2:1 ventriculoatrial conduction. An orange line is used to simultaneously align the retrograde p waves in the leads displayed. A QRS complex and a p wave are superimposed (in blue) on a QRS complex without retrograde atrial conduction to show the negative vector of the p wave (arrow) in lead II that is embedded within the up-sloping portion of the ST segment. View Large Image Figure Viewer Download Hi-res image

Abstract 18942: Coronary CT Angiography versus Stress Imaging for Initial Risk Stratification (CT-FIRST): A Randomized Prospective Trial on Downstream Resource Utilization

Introduction: Noninvasive stress myocardial imaging studies are commonly utilized to evaluate patients with chest pain. While coronary computed tomographic angiography (CTA) is highly accurate for the diagnosis of coronary artery disease (CAD), its comparative effectiveness versus stress imaging on downstream resource utilization is undefined. Hypothesis: We assessed the hypothesis that coronary CTA may be associated with lower downstream resource utilization as compared to stress imaging. Methods: We randomized 240 adults without prior CAD who were clinically referred for stress imaging (single photon emission computed tomography [SPECT] or stress echocardiography) to subsequent 64-slice CTA versus stress imaging alone (1:1). CTA readers were blinded to clinical and stress test results and patients were prospectively followed over 24 months for the primary outcome of mean per-patient downstream clinical evaluations and additional cardiac testing (composite) for the initial anginal complaint. Results: Patient were of mean age 52 ± 9 years (58% male) with mean pre-test probability (Diamond-Forrester) of 44 ± 20%. Most (67%) underwent SPECT (86% exercise), with 37% undergoing exercise stress echocardiography. Stress imaging studies demonstrated ischemia in 5% of subjects. Coronary CTA was normal in 52% with 40%, 5% and 1% having mild (<50%), moderate (50-69%) and severe (>70%) stenosis, respectively. Most patients (67%) underwent no further posttest evaluation. Coronary CTA was associated with significantly fewer total downstream encounters (0.4; 95% CI -0.5-1.4) versus no CTA (1.3; 0.9-1.6; p=0.02) and fewer clinic and emergency room visits per-subject (0.29 vs. 1.03; p=0.04). Downstream stress tests, catheterizations, revascularizations and acute coronary events were similar between groups. Discrepancies between CTA and stress imaging were rare (3 abnormal SPECT with normal CTA) and 9% of CTA patients required follow-up for incidental findings. There were no significant differences in aspirin or statin medication utilization. Conclusions: Among a stable symptomatic cohort with low CAD prevalence undergoing stress imaging, coronary CTA was associated with incrementally lower rates of downstream clinical evaluations.

Indications for and Outcomes of Tertiary Referrals in Refractive Surgery

To review the spectrum of disease, symptomatology, and management offered to patients referred for a second opinion after refractive surgery. A prospective cohort study was done on all patients referred from October 1, 2006, to September 30, 2011, to a tertiary eye clinic after refractive surgery of any kind (ie, corneal laser surgery, conductive keratoplasty, radial keratotomy, phakic implants, refractive lens exchanges, or any combination thereof). Data analysis was performed on all demographic and clinical aspects of this cohort, including the initial complaint, type of referral, number of complaints, procedure previously performed, diagnosis at our center, type of advice given, and rate and type of surgical intervention. One hundred thirty-one eyes (69 patients) were included. Corneal refractive surgery was performed in 82% (108 eyes), and 11% (14 eyes) were seen after phakic intraocular lens (PIOL) implantation and 7% (9 eyes) after refractive lens exchange. The most common diagnoses were tear film dysfunction (30 eyes, 23%), residual refractive error (25 eyes, 19%), and cataract (20 eyes, 15%). Most patients (42 patients, 61%) were treated conservatively. In 27 patients (39%), 36 eyes (28%) were managed surgically. Severe visual loss was seen in 1 eye. No major problems were found in most second opinions after refractive surgery referral. Dry eyes, small residual refractive error, or higher-order aberrations were the most common complaints. Surgical intervention was needed in 36 eyes (28%), almost half of which were cataract extractions. Severe visual loss was seen in 1 eye with a PIOL. There was no incidence of severe visual loss in keratorefractive and refractive lens exchange procedures.

Posterior Cortical Atrophy: Review of the Recent Literature

Posterior cortical atrophy (PCA) is a group of neurodegenerative dementing disorders characterized by initial predominant visual complaints followed by progressive decline in cognitive functions. The visuospatial and visuoperceptual defects arise from the dysfunction of, respectively, the dorsal (occipito-parietal) and the ventral (occipito-temporal) streams. Clinical symptoms, results of neuropsychological examination, and findings of posterior cerebral atrophy and/or posterior hypoperfusion/hypometabolism contribute to the diagnosis. However, owing to the insidious onset of PCA and the non-specificity of initial symptoms, the diagnosis is often delayed. Specific etiologies include Alzheimer's disease, dementia with Lewy bodies, subcortical gliosis, corticobasal degeneration, and prion-associated diseases. Alzheimer's disease accounts for at least 80 % of PCA cases. Recent research has concentrated on better defining the clinical presentation of PCA, improving neuroimaging analysis, testing new neuroimaging techniques, and developing biological measurements. Selected recent papers on PCA are reviewed in this article.

Unusual case of metachronous EBV‐associated B‐cell and NK/T‐cell lymphoma mimicking polymyositis‐diagnostic challenges and pitfalls

Unusual case of metachronous EBV‐associated B‐cell and NK/T‐cell lymphoma mimicking polymyositis‐diagnostic challenges and pitfalls

Electrophysiological assessment of hand elevation test in the diagnosis of carpal tunnel syndrome

Provided that the hand elevation test can reproduce the symptoms of carpal tunnel syndrome (CTS), this phenomenon prompted the idea of developing a simple test to diagnose CTS. The aim of this study was assess the electrophysiological values of the hand elevation test in the diagnosis of CTS syndrome. Thirty patients with initial symptoms and clinical signs of CTS in 49 hands were included. Special provocative tests for CTS were carried out before the hand elevation tests and the electrophysiological studies at least 5 min to avoid their effect on the intended test. The hand elevation test was performed and the test result was considered positive if symptoms occurred within 2 min. Nerve conduction study, including motor and sensory nerve conduction studies with F-wave study for both median nerves, was performed twice immediately before and after the hand elevation provocative test. This study was carried out on 60 hands; however, the initial complaint was in 49 hands, where the results showed a highly significant difference in parasthesia and hand pain, values of nerve conduction study (distal motor and sensory latencies) both before and after the hand elevation test, and a nonsignificant difference in the F-wave latencies. The posthand elevation distal motor and sensory latencies showed a sensitivity of 100 versus 78.6%, a specificity of 75 versus 81.2%, a positive predictive value of 77.8 versus 78.6%, and a negative predictive value of 100 versus 81.2%, respectively. Hand elevation is a simple provocative test that could be the physical examination of choice and can be used as a first-order provocative test instead of other tests for the diagnosis of CTS. Its significant provocative value was documented electrophysiologically.

Legg-Calvé-Perthes disease in children with Down syndrome

The aim of this study was to describe the features of Perthes disease in patients with Down syndrome. The data of this retrospective case series were collected between 2000 and 2011. Patients were assessed according to demographic, clinical and radiographic classifications. The study included 7 hips of 6 patients (5 males, 1 female). Mean age at first visit was 6.1 (range: 3.5 to 12.7) years and mean follow-up period was 52.3 (range: 30.2 to 90.8) months. Initial complaints were pain and limping with limited range of motion at the first visit. Range of motion tended toward early improvement despite continuous radiographic changes. One patient had late onset Perthes disease and developed rapid femoral head collapse managed with total hip arthroplasty. Perthes disease in children with Down syndrome must be followed despite clinical improvement. Radiographic characteristics of Perthes disease in patients with Down syndrome do not differ from those without it.

An Intervention Model That Promotes Accountability: Peer Messengers and Patient/Family Complaints

Patients and their families are well positioned to partner with health care organizations to help identify unsafe and dissatisfying behaviors and performance. A peer messenger process was designed by the Center for Professional and Patient Advocacy at Vanderbilt University Medical Center (Nashville, Tennessee) to address "high-risk" physicians identified through analysis of unsolicited patient complaints, a proxy for risk of lawsuits. This retrospective, descriptive study used peer messenger debriefing results from data-driven interventions at 16 geographically disparate community (n = 7) and academic (n = 9) medical centers in the United States. Some 178 physicians served as peer messengers, conducting interventions from 2005, through 2009 on 373 physicians identified as high risk. Most (97%) of the high-risk physicians received the feedback professionally, and 64% were "Responders." Responders' risk scores improved at least 15%, where Nonresponders' scores worsened (17%) or remained unchanged (19%) (p < or = .001). Responders were more often physicians practicing in medicine and surgery than emergency medicine physicians, had longer organizational tenures, and engaged in lengthier first-time intervention meetings with messengers. Years to achieve responder status correlated positively with initial communication-related complaints (r = .32, p < .001), but all complaint categories were equally likely to change over time. Peer messengers, recognized by leaders and appropriately supported with ongoing training, high-quality data, and evidence of positive outcomes, are willing to intervene with colleagues over an extended period of time. The physician peer messenger process reduces patient complaints and is adaptable to addressing unnecessary variation in other quality/safety metrics.

Evaluation of Sociodemographic Characteristics and the Relationship Between Initial Complaints and Histopathological Diagnosis of Patients Who Underwent Kidney Biopsy Procedure Between 2007-2011

Evaluation of Sociodemographic Characteristics and the Relationship Between Initial Complaints and Histopathological Diagnosis of Patients Who Underwent Kidney Biopsy Procedure Between 2007-2011

Skeletons in the Database: An Early Analysis of the CFPB's Consumer Complaints

Analyzing a new data set of 110,000 consumer complaints lodged with the Consumer Financial Protection Bureau, we find that (i) Bank of America, Citibank, and PNC Bank were significantly less timely in responding to consumer complaints than the average financial institution; (ii) consumers of some of the largest financial services providers, including Wells Fargo, Amex, and Bank of America, were significantly more likely than average to dispute the company‘s response to their initial complaints; and (iii) among companies that provide mortgages, OneWest Bank, HSBC, Nationstar Mortgage, and Bank of America all received more mortgage complaints relative to mortgages sold than other banks. In addition, regression analysis suggests that consumer financial companies respond differently to complaints about different products and based on different issues, generating significant differences in timeliness of response, as well as significant differences in whether consumers dispute that response. Moreover, demographics matter: there were significant increases in mortgage complaints per mortgage in ZIP codes with larger proportions of certain populations, including Blacks and Hispanics, as well as an increase in untimeliness and company responses disputed for groups on which the CFPB is mandated to focus, including senior citizens and college students.

Metastatic Calcaneal Lesion Associated with Uterine Carcinosarcoma

Metastatic lesions of uterine carcinosarcoma most commonly occur in the abdomen and lungs and less frequently in highly vascularized bone. We report a rare case of an 86-year-old female with uterine carcinosarcoma with metastasis to the left calcaneus. The patient had a history of uterine carcinosarcoma with hysterectomy and bilateral salpingo-oophorectomy, along with bilateral pelvic and aortic lymphadenectomy, with no adjuvant therapy. The initial pedal complaint was that of left foot pain. The initial radiographic findings were negative; however, magnetic resonance imaging scans revealed a substantial area of marrow edema in the calcaneus. An excisional biopsy was performed, and histopathologic analysis revealed adenocarcinoma with features consistent with the patient's previous uterine tumor specimen. The patient was given one treatment of chemotherapy and was discharged to a hospice, where she died of her disease 2 weeks later.

Short Read (Next-Generation) Sequencing

Rapid advances in DNA sequencing technologies have made it increasingly cost-effective to obtain accurate and timely large-scale genomic sequence data on individuals (short read massively parallel or next generation [next-gen]). A next-gen molecular diagnostic approach that has seen rapid deployment in the clinic over the last year is exome sequencing. Whole exome sequencing covers all protein-coding genes in the genome (≈1.1% of genome), and an exome test for a single patient generates ≈6 gigabases (109 bp) of DNA sequence data. A key challenge facing routine use of next-gen data in patient diagnosis and management is data interpretation. What sequence variant findings are relevant to diagnosis (pathogenic mutations)? What sequence variant findings are relevant to clinical care but not necessarily to patient diagnosis (clinically actionable incidental data)? What sequence information should be stored, and where can it be stored? This review provides a tutorial on current approaches to answering these questions. A recent landmark study showed that application of next-gen sequencing to a large cohort of idiopathic dilated cardiomyopathy patients found ≈27% of patients to show mutations of the titin gene, the most complex gene in the genome (363 exons). We use titin in cardiomyopathy as an exemplar for explaining next-gen sequencing approaches and data interpretation. Decreasing sequencing costs and broad dissemination of next-generation (next-gen) equipment and expertise are increasing availability of massively parallel sequencing of patient DNA samples (short read massively parallel or next-gen sequencing).1,2 Most rapidly expanding is exome sequencing, where all protein-coding sequences (exons) are selected from total genomic DNA and selectively sequenced.3 Alternative approaches to next-gen sequencing include targeted sequencing (TS) and whole genome (complete genome) sequencing. Currently, marketed targeted Sanger sequencing panels using traditional individual exon-by-exon sequencing remain expensive and time consuming, and massively parallel next-gen approaches are beginning to supplant …

The feasibility score for the Laparoscopic Appendicitis Score

We appreciate the comment of Liu and Lu on our article. In response to their first concern about the fecaliths, we agree with the statement that fecaliths are associated with appendicitis and perforation of the appendix. We are unsure whether the presence of fecaliths should be an item in the Laparoscopic Appendicitis Score (LAPP score). Therefore, we retrospectively analyzed all high-definition videos we took from the 25 normal appendices. As described in our Methods section, all appendices were thoroughly evaluated by the surgeon, and this was captured on video. In none of the 25 normal appendices a fecalith was present. Therefore, in our opinion, a fecalith in a normal appendix is very rarely seen and probably not relevant. However, we believe that in our planned large multicenter study, we should prospectively register the presence of fecaliths. We agree with the authors that a thickened peritoneum around the appendix caused by other intraabdominal pathology should not be a reason for an appendectomy. In our view, it is not difficult for surgeons to differentiate a thickened appendix or mesoappendix from appendicitis or from peritonitis caused by other pathology. We do not agree with the last concern raised by Liu and Lu. In our view, there is no literature on the interval between the onset of symptoms and the intraoperative appearance of the appendix. We speculate that in case the patient has right iliac fossa pain from appendicitis, there is peritonitis and thus the peritoneum or appendix is thickened. We saw 17 of our patients within 12 h of their initial complaints, and we did not notice any difference between the appearance of their appendices and those of patients with a longer duration of symptoms. Notably, 5 of these 17 appendices were necrotic (29 %), and 7 of the patients had pus around their appendix (41 %). In comparison, for all the patients with appendicitis (n = 109), this was a 28 % rate for necrosis and a 53 % rate for pus.

Analysis of a case series of behavioral variant frontotemporal dementia: emphasis on diagnostic delay.

INTRODUCTIONDespite many advances in the characterization of the behavioral variant of frontotemporal dementia (bvFTD), the diagnosis of this syndrome poses a significant challenge, while delays or diagnostic mistakes may impact the proper clinical management of these patients.OBJECTIVETo describe the clinical profile at first evaluation of a sample of patients with bvFTD from a specialized outpatient neurological unit, with emphasis on the analysis of the delay between the onset of symptoms and diagnosis.METHODSWe selected 31 patients that fulfilled international consensus criteria for possible or probable bvFTD. Patients' medical admission sheets were thoroughly reviewed.RESULTSPatients' mean age was 67.9±8.2 years; 16 (51.6%) were men. Mean number of years of formal education was 7.7±4.0 years. Mean age at onset was 62.2±7.7 years, indicating a mean of 5.8 years of diagnostic delay. Thirteen patients (41.9%) presented with initial behavioral complaints only, eleven patients (35.5%) had mixed behavioral and memory complaints, five patients (16.1%) presented with memory complaints only, and two patient (6.4%) had behavioral and speech problems. Nine patients (29%) were admitted with alternative diagnoses. Mean and standard deviation scores for the mini-mental state examination, animal category fluency and memory test for drawings (five-minute delayed recall) were 19.3±6.3, 8.3±4.1and 3.7±2.7, respectively.CONCLUSIONMost patients from this sample were evaluated almost six years after the onset of symptoms and performed poorly on both cognitive screening tests and functional evaluation measures.