Missed Treatment Opportunities Research Articles

Too Weak to Breathe: An Odd Case of Lambert Eaton Myasthenic Syndrome

SESSION TITLE: Critical Care 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Lambert Eaton Myasthenic Syndrome (LEMS) is a rare autoimmune disorder of the neuromuscular junction characterized by the presence of antibodies against voltage gated calcium channels (VGCC) often associated with an underlying neoplasm. CASE PRESENTATION: 52 year old Caucasian female was admitted to an outside hospital with lethargy, shortness of breath and was intubated for acute hypercapnic respiratory failure which ultimately resolved and she was extubated. Her discharge diagnosis was presumed obstructive sleep apnea. Three weeks later she presented to our hospital with the same symptoms. Physical exam was significant for diminished breath sounds bilaterally and musculoskeletal exam was normal on presentation. Arterial blood gas was 7.26/79/118/35 after 30 minutes on non-invasive positive pressure ventilation, prompting intubation. On the ventilator she was awake and alert without sedation, but failed repeated breathing trials due to apnea, low tidal volumes and a negative inspiratory force of -10 cmH2O. Her persistant, profound and unexplained respiratory muscle weakness, raised concerns for a neuromuscular disorder and neurology was consulted. Electromyogram and nerve conduction studies revealed a post exercise increase in compound muscle action potential response > 200%, her VGCC antibodies were positive and acetylcholine receptor antibodies were negative. Computerized Tomography of the chest demonstrated a right suprahilar mass with a paratracheal lymph node which was hypermetabolic on Positron Emission Tomography. Endobronchial Ultrasound with biopsy of the lymph node confirmed small cell lung carcinoma. She was treated with pyridostigmine and plasma exchange with excellent response and was extubated several days later. She received three cycles of etoposide, cisplatin, chest radiation and is currently on mestinon and 3,4 diaminopyridine for her LEMS. DISCUSSION: LEMS classically presents as proximal muscle weakness, autonomic dysfunction and areflexia. Respiratory failure is a common primary manifestation of Myasthenia Gravis, however the literature rarely documents LEMS as presenting this way. This case highlights the importance of considering occult neuromuscular diseases in cases of unexplained respiratory failure even if other classical symptoms such as muscle weakness are absent. Our patient had repeated episodes of respiratory failure requiring intubation that was initially misdiagnosed, leading to missed treatment opportunities, a poor quality of life and an unchecked pulmonary malignancy. CONCLUSIONS: LEMS often presents early in the neoplastic course, thus diagnosis has important implications. Treatment of LEMS can be effective in relieving the neuromuscular symptoms and early detection of the underlying malignancy can be lifesaving. Reference #1: Fatima. U., Shah. T., Dedhia.P., Devine. S., Lambert Eaton Syndrome: Unique Presentation of the Disease with Isolated Respiratory Muscle Weakness. CHEST. Abstract 326A. October 2013. DISCLOSURE: The following authors have nothing to disclose: Caryn Brehm, Christopher Barrios, James Caress, Daniel Files, Daniel LoVerde No Product/Research Disclosure Information

The Impact of Missed Treatment Opportunities on Outcomes In Hospitalised Heart Failure Patients: Modelling Analysis Based on The National Heart Failure Audit

The Impact of Missed Treatment Opportunities on Outcomes In Hospitalised Heart Failure Patients: Modelling Analysis Based on The National Heart Failure Audit

A retrospective analysis of delays in the diagnosis of lung cancer and associated costs.

PurposeDiagnosis of lung cancer at advanced stages can result in missed treatment opportunities, worse outcomes, and higher health care costs. This study evaluated the wait time to diagnose non-small-cell lung cancer (NSCLC) and the cost of diagnosis and treatment based on the stage at diagnosis.Patients and methodsAdult patients diagnosed with NSCLC between January 2007 and September 2011 were identified from a proprietary oncology registry and linked to health insurance claims from a large US health insurance company. Continuous enrollment in the health plan was required for at least 12 months prediagnosis (baseline) and at least 3 months postdiagnosis (follow-up). Use of diagnostic tests and time to diagnosis were examined. The rates of health care utilization and per-patient per-month (PPPM) health care costs were calculated.ResultsA total of 1,210 patients with NSCLC were included in the analysis. Most patients (93.6%) had evidence of diagnostic tests beginning 5 to 6 months prior to diagnosis, and most were diagnosed at an advanced stage (23% Stage IIIb and 46% Stage IV). The PPPM total health care costs in USD pre- and postdiagnosis were $2,407±$3,364 (mean±standard deviation) and $16,577±$33,550, respectively. PPPM total health care costs and utilization after lung cancer diagnosis were significantly higher among patients diagnosed at Stage IV disease and lowest among patients diagnosed at Stage I disease ($7,239 Stage I, $9,484 Stage II, $11,193 Stage IIIa, $17,415 Stage IIIb, and $21,441 Stage IV).ConclusionThis study showed that most patients experienced long periods of delay between their first diagnostic test for lung cancer and a definitive diagnosis, and the majority were diagnosed at advanced stages of disease. Costs associated with the management of lung cancer increased substantially with higher stages at diagnosis. Procedures that diagnose lung cancer at earlier stages may allow for less resource use and costs among patients with lung cancer.

An Epidemiological Overview of Chronic Obstructive Pulmonary Disease: What Can Real-Life Data Tell Us about Disease Management?

ABSTRACTChronic obstructive pulmonary disease (COPD) is a common condition, associated with increasing age and smoking exposure. COPD is a leading cause of morbidity, mortality and health care expenditure worldwide; yet, only 10–15% of all cases are identified medically. Alpha-1-antitrypsin deficiency (AATD) is responsible for about 1% of COPD cases but is also largely under-recognised, leading to diagnostic delay and missed treatment opportunities in patients who remain undetected. New evidence has recently highlighted the extent of overlap between COPD and bronchiectasis and the implications of comorbidity on clinical course and mortality. COPD with comorbid bronchiectasis deserves to be given research priority. This article overviews the epidemiology of COPD and examines the implications of overlap between COPD and AATD and between COPD and bronchiectasis.

PreSSUB II: The prehospital stroke study at the Universitair Ziekenhuis Brussel II.

RationaleStroke is a time-critical medical emergency requiring specialized treatment. Prehospital delay contributes significantly to delayed or missed treatment opportunities. In-ambulance telemedicine can bring stroke expertise to the prehospital arena and facilitate this complex diagnostic and therapeutic process.AimsThis study evaluates the efficacy, safety, feasibility, reliability and cost-effectiveness of in-ambulance telemedicine for patients with suspicion of acute stroke. We hypothesize that this approach will reduce the delay to in-hospital treatment by streamlining the diagnostic process and that prehospital stroke care will be improved by expert stroke support via telemedicine during the ambulance transportation.DesignPreSSUB II is an interventional, prospective, randomized, open-blinded, end-point, single-center trial comparing standard emergency care by the Paramedic Intervention Team of the Universitair Ziekenhuis Brussel (control) with standard emergency care complemented with in-ambulance teleconsultation service by stroke experts (PreSSUB).Study OutcomesThe primary efficacy endpoint is the call-to-brain imaging time. Secondary endpoints for the efficacy analysis include the prevalence of medical events diagnosed and corrected during in-ambulance teleconsultation, the proportion of patients with ischemic stroke receiving recanalization therapy, the assessment of disability, functional status, quality of life and overall well-being. Mortality at 90 days after stroke is the primary safety endpoint. Secondary safety analysis will involve the registration of any adverse event. Other analyses include assessment of feasibility and reliability and a health economic evaluation.

Measuring the Level of Agreement Between a Veterinary and a Human Point-of-Care Glucometer and a Laboratory Blood Analyzer in Hispaniolan Amazon Parrots (Amazona ventralis)

Although abnormalities in blood glucose concentrations in avian species are not as common as they are in mammals, the inability to provide point-of-care glucose measurement likely results in underreporting and missed treatment opportunities. A veterinary glucometer that uses different optimization codes for specific groups of animals has been produced. To obtain data for a psittacine bird-specific optimization code, as well as to calculate agreement between the veterinary glucometer, a standard human glucometer, and a laboratory analyzer, blood samples were obtained from 25 Hispaniolan Amazon parrots (Amazona ventralis) in a 2-phase study. In the initial phase, blood samples were obtained from 20 parrots twice at a 2-week interval. For each sample, the packed cell volume was determined, and the blood glucose concentration was measured by the veterinary glucometer. The rest of each sample was placed into a lithium heparin microtainer tube and centrifuged, and plasma was removed and frozen at -30 degrees C. Within 5 days, tubes were thawed, and blood glucose concentrations were measured with a laboratory analyzer. The data from both procedures were used to develop a psittacine bird-specific code. For the second phase of the study, the same procedure was repeated twice at a 2-week interval in 25 birds to determine agreement between the veterinary glucometer, a standard human glucometer, and a laboratory analyzer. Neither glucometer was in good agreement with the laboratory analyzer (veterinary glucometer bias, 9.0; level of agreement, -38.1 to 56.2; standard glucometer bias, 69.4; level of agreement -17.8 to 156.7). Based on these results, the use of handheld glucometers in the diagnostic testing of Hispaniolan Amazon parrots and other psittacine birds cannot be recommended.

Validation of the non-motor symptoms questionnaire (NMS-Quest)

Background Although non-motor manifestations of Parkinson’s disease are common and can cause severe disability, they are often under-recognized, leading to missed treatment opportunities. Screening tools for non-motor symptoms are urgently needed. Recently a 30–item screening Non Motor Symptoms Questionnaire was developed. Although some psychometric properties have been evaluated, sensitivity and specificity of the questionnaire have not been systematically assessed. Methods Parkinson patients completed Non Motor Symptoms Questionnaire, then underwent a gold-standard clinical evaluation of non-motor symptoms and signs that included extensive standardized questionnaires, cognitive/behavioural assessment, and neurological examination to determine whether each manifestation was present or absent. The sensitivity and specificity of each non-motor symptom, in relation to the gold-standard were estimated. Results For the 70 participants, the mean age was 66.7+/−9.3, 64% were men, and disease duration was 3.8+/−2.8 years. From the gold-standard evaluation, the prevalence of non-motor manifestations ranged from 8.7% (hallucinations) to 78.3% (nocturia). The mean sensitivity of all Non Motor Symptoms was 63.4%. This varied considerably among different manifestations, ranging from 24% (sleepiness, hyposmia) to 100% (diplopia). By restricting analysis to clinically significant non-motor problems (i.e. those serious enough to warrant treatment), the mean sensitivity increased to 71.8%. The specificity for most items was high, with an overall mean specificity of 88.5%. Conclusions For many non-motor manifestations Non Motor Symptoms Questionnaire is an effective screen; however, for manifestations such as somnolence, olfactory loss and apathy, sensitivity is suboptimal. Overall, this questionnaire can be a useful clinical tool for screening non-motor problems in an office setting.

Missed treatment opportunities: A prospective observational cohort study of patients admitted with hip fractures

Missed treatment opportunities: A prospective observational cohort study of patients admitted with hip fractures

With Money in Short Supply, Psychiatrists Urged to Be Creative

With Money in Short Supply, Psychiatrists Urged to Be Creative

Missed treatment opportunities for schistosomiasis mansoni, in an active programme for the treatment of urinary schistosomiasis in Plateau and Nasarawa states, Nigeria

Both Schistosoma haematobium and S. mansoni are endemic in Nigeria. Since 1999 the ministries of health of Plateau and Nasarawa states, assisted by The Carter Center, have provided mass drug administrations with praziquantel to villages where >20% of the school-aged children tested with urine dipsticks have been found to have haematuria (presumed to be caused by S. haematobium). The current extent of S. mansoni in Nigeria remains relatively unknown because the tests needed to detect human infection with this parasite are difficult to perform in many endemic areas. In a cross-sectional survey involving 924 children, the prevalence of S. mansoni was determined in 30 villages (in four local government areas) that had been excluded from mass praziquantel administrations because the prevalence of haematuria in their school-aged children had been found to be <20%. Seventeen (57%) of the surveyed villages had sufficient S. mansoni (i.e. prevalences of at least 10%) to warrant treatment. The results indicated that, if both S. haematobium and S. mansoni are taken into account, 81% of the villages in the four local government areas studied require treatment, compared with 50% if only S. haematobium is considered. At the moment, the costs of the village-by-village diagnosis of S. haematobium and S. mansoni would be greater than those of the presumptive treatment of the school-aged children in all villages. Until improved and cheaper rapid diagnostic methods for S. mansoni become available, the cheapest approach to the overall problem of schistosomiasis in this part of Nigeria would therefore be wide-spread mass drug distributions, without screening for at-risk populations.

Older Survivors and Cancer Care

The current sizeable population of cancer survivors has brought to the forefront key issues related to treatment decisions, management of adverse consequences of cancer and its treatment, and complex health needs related to cancer and other chronic comorbid conditions ( 1 ). Although improvements in cancer diagnosis, early detection, and treatment have led to dramatically increasing numbers of cancer survivors, cancer continues to be the second most common cause of death in the United States, and an estimated 1 444 920 new patients are expected to be diagnosed with cancer during this year alone ( 2 ). Cancer survivorship research focuses on the health and life of individuals living with the late or long-term effects of can cer or its treatment(s). By defi nition, patients living with advanced disease are cancer survivors. Individuals older than age 65 account for 60% of the estimated 10.8 million cancer survivors in the United States today ( 1 ). With the aging of the population, a rising trend in numbers of older cancer survivors is expected. Given the median age at diagnosis (67 years; all sites combined) and increasing survival estimates, comorbid conditions, especially among older survivors, are and will be an important factor in treatment decisions, posttreatment follow-up care, and palliative care ( 3 , 4 ). Studies have demonstrated that the presence of comorbid health conditions and perceived health vulnerability of the elderly by physicians can lead to under- or less aggressive treatment of the elderly, with resulting poor prognoses. Comorbidity in older patients may limit the ability to obtain (or for patients to undergo procedures that furnish) prognostic information (eg, axillary lymph node dissection), minimize treatment options (eg, breast-conserving therapy), and increase the risk of death from causes other than cancer ( 5 ). We propose that “cancer-related care” can be envisioned at four levels: 1) acute treatment of the cancer; 2) surveillance and follow-up care for disease recurrence, management of adverse treatment – related consequences and noncancer comorbidities; 3) palliative care for advanced cancer; and 4) end-of-life care. Supportive and palliative care have been recognized as important components of quality care for all cancer patients, particularly for those with advanced or incurable disease ( 6 , 7 ). Although it is increasingly accepted that quality palliative care should be provided through an interdisciplinary team approach with a focus on comfort and quality of life ( 8 ), the lack of a strong evidence-based foundation for this important area of research may result in missed treatment opportunities, the provision of nonbenefi cial and burdensome interventions, and over- or undertreatment ( 9 , 10 ). Within palliative surgery and other invasive specialty areas, specifi c concerns include the risks of major morbidity and mortality associated with many cancer-specifi c treatment approaches and the impact of decreased or severely restricted decision-making capacity among patients, especially those who are frail and elderly. The diversity of ethnic, cultural, and religious backgrounds of patients experiencing life- threatening illness at older ages adds further complexity to the provision of acceptable and optimal cancerrelated care. The fact that the Medicaid-insured nursing home patients studied by Bradley et al. ( 11 ), as reported in this issue of the Journal, had a preponderance of late and unstaged disease, high mortality within a few months of diagnosis, low hospice utilization, and little cancer-directed treatment is of concern, and future studies should further examine these issues. Timely cancer treatment and the alleviation of symptoms have the potential to extend life and enhance the quality of survival. Especially noteworthy are the fi ndings that 1) relative to patients aged 86 years and older (the fastestgrowing segment of the US population), patients aged 76 – 80 years and 81 – 85 years were less likely to be diagnosed with late or unstaged cancer at diagnosis; and 2) compared with patients with breast cancer, patients with colorectal, lung, prostate, and other cancers were more likely to be diagnosed with late or unstaged cancer. These results in particular underscore the fact that within the overarching category of “older survivors”, complexities related to early detection and management of the disease increase with age. In addition, some cancers other than breast cancer tended to have been diagnosed relatively late in this study, highlighting the need for vigilance toward possible cancer-related symptoms for some common cancers. These fi ndings also might refl ect the impact of established guidelines and practices relating to mammograms, as opposed to inconsistencies regarding prostate-specifi c antigen testing, colonoscopy, and screening for lung cancer.

Integrating the care of HIV and TB in developing countries

National TB programs (NTP) in countries with high HIV prevalence have been confronted with increased TB case loads. The complexity of management of TB has been complicated by smear-negative extrapulmonary disease, high mortality and an association with drug-resistant TB. As a result of international funding, access to antiretroviral therapy (ART) has rapidly expanded. NTP and HIV/ART programs have developed separately and HIV/TB patients receive care in two programs, resulting in duplication of care, and missed treatment opportunities. Collaboration between the services has been successfully demonstrated at strategic levels, national surveillance and in small pilot projects at hospital and clinic level. However, streamlining of services alone will not restore TB control in high HIV prevalence settings. HIV/TB control will require both expanded TB program capacity to detect and treat TB cases earlier in order to decrease the infective pool, and HIV services will need to expand ART coverage to decrease the ...

Gonorrhea and chlamydia in emergency departments: Screening, diagnosis, and treatment

Failure to screen sexually active adolescents and adults for gonorrhea and chlamydia at the time of acute care visits to urban emergency departments (ED) results in missed treatment opportunities for 38% to 82% of infected persons. The prevalence of gonorrhea and chlamydia infections among ED patients presenting with genitourinary or pregnancy-related complaints or providing urine specimens as part of routine medical care ranges from 4.3% to 16.4%. Notably, prevalence among general ED patients is similar (9.7%-14.3%). Due to the asymptomatic or nonspecific presentation of these infections, expanded screening is recommended to increase detection, treatment, and partner notification. A lower threshold of empiric treatment in the ED setting is recommended due to the difficulty and incompleteness of follow-up subsequent to ED discharge. Specific recommendations to improve the quality of ED care for sexually transmitted infections and to expand detection are provided.

Regional Differences in Breast Cancer Survival Despite Common Guidelines

Despite a uniform regional breast cancer care program, breast cancer survival differs within regions. We therefore examined breast cancer survival in relation to differences in diagnostic activity, tumor characteristics, and treatment in seven Swedish counties within a single health care region. We conducted a population-based observational study using a clinical breast cancer register in one Swedish health care region. Eligible women (n = 7,656) ages 40 to 69 years diagnosed with primary breast cancer between 1992 and 2002 were followed up until 2003. The 7-year relative survival ratio was used to estimate breast cancer survival. Excess mortality was modeled using Poisson regression to study differences in survival between counties. The 7-year relative survival for breast cancer patients was significantly lower (up to 7% in absolute risk difference) in one county (county A) compared with the others. This difference existed only among women diagnosed before 1998, ages 50 to 59 years, and was strongest among stage II breast cancer patients. Adjustment for amount of diagnostic activity eliminated the survival differences among the counties. The amount of diagnostic activity was also lower in county A during the same time period. After county A, during 1997-1998, began to adhere strictly to the regional breast cancer care program, neither any survival differences nor diagnostic activity differences were observed. Markers of diagnostic activity explained survival differences within our region, and the underlying mechanisms may be several. Low diagnostic activity may entail later diagnosis or inadequate characterization of the tumor and thereby missed treatment opportunities. Strengthening of multidisciplinary management of breast cancer can improve survival.

Missed treatment opportunities, for pregnant and breast-feeding women, in onchocerciasis mass-treatment programmes in south–eastern Nigeria

During annual rounds of mass treatment against onchocerciasis, women who are pregnant or nursing neonates should not to be offered ivermectin. The aim of the present study was to determine how many women were not treated, as a result of this policy, in four villages in south-eastern Nigeria. Of the 1714 women of reproductive age present during the 2000 round of mass treatment, 599 (35%) were excluded because they were pregnant or nursing babies aged < 1 month. Most (56%) of the 599 excluded women were, however, treated individually later in the year. Of the 264 excluded women who did not receive a dose of ivermectin at all in 2000, 123 (47%) said they would have actively sought ivermectin treatment had they been made aware of the short duration of exclusion for nursing. If they had all known of the short duration of the exclusion and when and how to locate and receive treatment in their villages after the round of mass treatment, 91% of the women excluded from the round of mass treatment would probably have been treated later in the year. Better treatment systems, follow-up and health education, targeted at pregnant and lactating women, would improve treatment coverage of this group after parturition and early nursing.