Protocol For Evaluation Of Patients Research Articles

Conectividad funcional en un paciente con alucinaciones complejas. Un caso de autoscopia

La autoscopia, del griego autos (sí mismo) y skopeo (mirar), son alucinaciones complejas durante las cuales el paciente experimenta una duplicación visual de su cuerpo. El presente artículo discute algunos correlatos de conectividad cerebral obtenida por resonancia funcional en reposo, en una paciente con epilepsia refractaria y alucinaciones autoscópicas durante sus crisis.
 El objetivo es presentar los hallazgos por neuroimágenes funcionales de una paciente que presenta alucinaciones del tipo autoscópico.
 Como parte del protocolo de evaluación de pacientes con epilepsia refractaria se realiza examen de videomonitoreo electroencefalográfico, imágenes de tomografía por emisión de positrones e imágenes de resonancia magnética funcional en reposo a una paciente que sufre alucinaciones autoscópicas durante las crisis. La información obtenida por estos estudios se correlaciona con la información clínica.
 En la paciente, el estudio de tomografía por emisión de positrones y el videomonitoreo electroencefalográfico indican alteraciones en el lóbulo occipital derecho, hallazgos que coinciden con reportes en la literatura sobre autoscopia. La sincronización neuronal, medida por resonancia funcional, es anormal en la misma región alterada en la tomografía por emisión de positrones, permitiendo relacionar el fenómeno autoscópico con cambios de la conectividad cerebral. La paciente cuenta con características clínicas de alucinación autoscópica. La resonancia magnética indica zonas con alteraciones de la dinámica cerebral que, en el caso de la paciente, coinciden con regiones reportadas en la literatura. El presente estudio aporta evidencias sobre el papel de los mecanismos de sincronización neuronal y la percepción de alucinaciones.

Systemic evaluation of cutaneous sarcoidosis: 15-year dermatology experience at University Hospital Limerick.

Sarcoidosis is a multisystem granulomatous disease that can affect almost any organ including the skin, liver, ocular, cardiac, renal, nervous, musculoskeletal and endocrine systems. Systemic evaluation is indicated in all patients diagnosed with cutaneous sarcoidosis, as it is associated with asymptomatic systemic disease in 30%-40% of patients. Guidelines recommend that patients diagnosed with sarcoidosis undergo baseline and surveillance investigations including full blood count (FBC), renal and liver profile, Vitamin D, serum calcium, electrocardiography (ECG), chest radiography, pulmonary function tests (PFTs) and ophthalmology examination to assess for systemic involvement. Recommendations for surveillance monitoring vary on interval duration but include regular FBC, biochemistry, chest radiography and PFTs, with additional investigations and prompt referral to respective specialties as indicated.. We conducted a retrospective analysis to evaluate extracutaneous involvement and systemic evaluation of patients diagnosed with cutaneous sarcoidosis during the period 2004-2020, and compared our findings with international guidelines. Cutaneous manifestation was the primary presentation for 67% of the patients (12 of 18), an extracutaneous disease subsequently developed in 67% (8 of 12) of these patients. Baseline investigations included chest radiography (94%; 17 of 18), PFTs (39%; 7 of 18), FBC (94% (17 of 18), renal profile (89%; 16 of 18), liver function tests (83%; 15 of 18) and serum calcium (89%; 16 of 18); ECG was performed for 4 (25%) of 16 patients. No Vitamin D levels were recorded. Specialist referral was required for 89% (16 of 18); of these 16 patients, 94% (15 of 16) required referral to the Respiratory Medicine department, 69% (11 of 16) to Ophthalmology and 19% (3 of 16) to Nephrology. The results highlight the importance of a structured protocol for the systemic evaluation of patients diagnosed with cutaneous sarcoidosis. We subsequently developed a baseline and surveillance protocol for the assessment of extracutaneous disease in patients at University Hospital Limerick.

Key considerations for elective surgery in patients who previously had COVID-19.

Key considerations for elective surgery in patients who previously had COVID-19.

299 Epidemiology of leukocytoclastic vasculitis: A multicenter retrospective review of 440 patients

Leukocytoclastic vasculitis (LCV) may be idiopathic or associated with underlying disorders. The aim of this study was to evaluate the demographics, comorbid diseases, and causes of LCV in a large cohort. A multicenter retrospective review at Massachusetts General Hospital, Brigham and Women’s Hospital, and the Hospital of the University of Pennsylvania between the years of 2000 and 2014 identified 440 patients with LCV confirmed by histology. 56.1% of patients were male, and 43.9% were female. Age ranged from 18 to 93 years (mean, 55). The most common comorbidities at the time of diagnosis were active cancer (13.2%), renal insufficiency (8.9%), and hepatitis B or C (7.5%). Recent past medical history included antibiotic use (46.8%), upper respiratory infection (8.0%), and pneumonia (5.0%). Common symptoms at presentation included fever (24.8%), pruritus (22.7%), and joint pain (19.3%). 80.2% (353/440) of patients were diagnosed with skin-limited LCV. The remaining patients were diagnosed with systemic vasculitis, of which the most common subtype was IgA vasculitis (12.0%), or underlying connective tissue disease (3.0%). Of patients who had skin-limited LCV, the etiology was most commonly “idiopathic” (60.3%, 213/353), followed by medication exposure (27.5%, 97/353). Less common etiologies of skin-limited LCV included infections (9.9%) and malignancy (2.0%). This study demonstrates that over 80% of initial episodes of LCV are skin-limited, and approximately 60% of these cases are idiopathic. The prevalence of known etiologies can help dictate the evaluation and treatment of patients presenting with LCV. Future studies should focus on establishing a protocol for evidence-based evaluation of patients presenting with LCV.

Abstract TP277: A Hospital’s Perspective: Economic Evaluation of Hospitalization vs Rapid Outpatient Evaluation for TIA and Minor Strokes

Introduction: Patients presenting to emergency departments (ED) with TIA and minor strokes (TIAMS) are often admitted for expedited evaluation, though outpatient care models have been proposed. We piloted a rapid outpatient evaluation protocol for patients presenting with TIAMS within 24 hours of ED discharge. We hypothesized that this approach would reduce hospital costs and length of stay (LOS). Methods: This analysis looked at patients presenting to our institution’s ED with TIAMS (NIHSS < 5) in calendar year 2017. We compared hospitalization LOS, costs and expected revenues between admitted patients and those referred for rapid outpatient evaluation. Patients eligible for outpatient evaluation were without disabling deficits, recurrent symptoms, new-onset atrial fibrillation, prior carotid imaging with >50% stenosis, and not receiving thrombolysis. Disabling deficits were defined as new gait impairments, significant motor weakness, hemianopia, dysphagia or severe aphasia. Cost data was obtained from our finance department and expected revenue was estimated using Medicare reimbursement data, assuming Medicare-Fee for Service as the primary payer for all patients. Results: We identified 92 patients referred to our rapid outpatient clinic and 90 admitted patients (mean NIHSS 0.8 vs 1.8 respectively). In comparison to patients who were admitted, patients referred to outpatient evaluation had shorter hospital stays, lower total hospitalization costs, and decreased net-losses after accounting for expected revenue (Table). Only one patient in the outpatient cohort was readmitted for further management. Overall, the one-year pilot cohort averted approximately 138 bed-days and $950,000 in hospitalization costs. Conclusions: For patients who presented to our ED with TIAMS without disabling deficits, rapid outpatient evaluation reduced hospital LOS and total costs. Further research is needed to incorporate costs to payers and patients.

Should susceptibility-weighted imaging be included in the protocol for evaluation of acute ischemic stroke patients?

Context: Stroke is one of the leading causes of death globally and is a major cause of long-term disability. Aims of Study: (1) To identify hemorrhagic foci in patients with acute ischemic stroke by susceptibility-weighted imaging (SWI). (2) To compare the detection of hemorrhagic foci in patients with acute ischemic stroke by SWI versus conventional magnetic resonance imaging (MRI) (T1-weighted, T2-weighted, and fluid-attenuated inversion recovery [FLAIR]). Materials and Methods: Two-hundred and fifty patients, who clinically presented with neurological deficit, were evaluated using 1.5 Tesla MRI scanner from October 2011 to September 2013 with the above sequences. Detection of hemorrhage in acute infarct was evaluated and compared. Results: Of 250 patients evaluated in this study, 232 cases were arterial infarcts and 18 cases were venous infarcts. Hemorrhage was detected in 86 (34.4%) patients, of which 68 cases were from arterial infarcts and 18 were from venous infarcts. SWI was significantly sensitive and specific (P < 0.004) for the detection of hemorrhage in acute infarct compared to T1-weighted, T2-weighted, and FLAIR. Conclusion: SWI is a very sensitive sequence for the detection of hemorrhage in acute stroke patients. Therefore, its use is recommended in the protocol for evaluation of these patients.

Abstract 14805: Use of Dedicated Protocol and Implantable Loop Recorder to Evaluate for Atrial Fibrillation in Cryptogenic Stroke Patients: Real World Validation of Crystal AF

Introduction: Embolic strokes related to atrial fibrillation (AF) carry significant morbidity and mortality. Identifying patients with asymptomatic AF following stroke is difficult. A protocol for incorporation of implantable loop recorders (ILR) in stroke management has not been established. Methods: We developed a protocol for evaluation of patients with cryptogenic embolic stroke using ILR for detection of AF (figure 1). Patients implanted with ILR were enrolled in an AF clinic with structured remote follow-up. The primary end point was time to first detected AF. Secondary end point was time to initiation of anticoagulation following identification of AF. Results: 95 patients underwent ILR placement. Baseline characteristics are shown in table 1. The median time between stroke and ILR placement was 6 days with a range of 1 to 496 days. The mean follow-up time was 169.4 +/- 103.1days. 18 patients (18.9%) had AF detected during the study period (Figure 2). Mean time to detection of AF was 95.7 +/- 93.6 days. 94.4% were anticoagulated (52.9% Rivaroxaban, 41.2% Apixaban, 5.9% Warfarin). The median time from detection of AF to initiation of anticoagulation was 2 days with a range of 1 to 28 days. Conclusions: A protocol for incorporating ILR in evaluation of embolic cryptogenic stroke can improve AF detection and time to initiation of anticoagulation.

Electromyographic study on the sternocleidomastoid and pectoralis major muscles during respiratory activity in humans

Abstract Introduction: This study aimed to evaluate the simultaneous and maximum activities ofthe sternocleidomastoid (SCM) and pectoralis major (PM) muscles, to determine how the two types of breathing patterns (normal and forced) can affect these activities , and to verify which of these muscles could be used to establish an evaluation protocol for patients undergoing mechanical ventilation. Methods: Eleven healthy men, aged 18 to 25 years, participated in this study. The individuals remained in supine position using a respiratory belt to monitor both inspiratory and expiratory phase during shifts in the rib cage, performing three repetitions for the normal and forced respiratory movements, while keeping the breathing rhythm with a standard metronome. Electromyographic signals were captured using bipolar surface electrodes placed on the lower third of the SCM muscle and on the lower PM muscle fibers. Electromyographic signals were analyzed and the root mean square (RMS) values were calculated for a complete respiratory cycle. The EMG values were analyzed using the Bonferroni test for multiple comparisons. The homogeneity of variances was verified using the logarithmic transformation (LOG). The level of statistical significance was set at 5% (SPSS 19.0). Results: The values showed that there are signiicant differences between the EMG values of the SCM muscle during normal and forced respiration and the EMG values of the ECM and PM muscles during forced respiration. Conclusion: These results showed that the SCM muscle can be an indicator for the development of parameters to be used in the analysis of patients with respiratory failure.

Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification

Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates. To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol's implementation. Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation. Patients presenting for alcohol detoxification. Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification. Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation. We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p = 0.037). There was no difference in readmission rate or length of stay. Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.

Computer protocol for the electrodiagnostic evaluation of patients with suspected median neuropathy at the wrist

Patients with median entrapment neuropathy at the wrist (MEW) present a large burden to electrodiagnostic (EDx) services. We report here our experience with a computer protocol for EDx standardized evaluation of these patients. The computer program guiding the examiners through the history, focused clinical examination and nerve conduction studies (NCSs), and automatically generating the report was employed in patients with suspected MEW referred to our unit in year 2010. Included were 1,935 patients (3,870 hands) with suspected MEW. Median motor study had to be performed in 100 %, a ring finger sensory comparison study in 99 %, a thumb study in 23 %, wrist study in 3 % and a middle finger study in 19 % of hands with cumulative sensitivities of 45, 68, 73, 74, and 82 %, respectively. In conclusion, our computer program helped to relieve some burden, standardized NCSs and provided data needed to further develop evidence-based protocol for the NCSs in patients with suspected MEW.

CT Angiography in an Acute Stroke Protocol: Correlation between Occlusion Site and Outcome of Intravenous Thrombolysis

Thrombolysis with intravenous rt-PA is the current therapy for acute ischemic stroke. Unlike other outcome factors, relatively little is known about the prognostic value of the occlusion site on treatment outcome. We compared the effectiveness and safety of intravenous thrombolysis in patients with different levels of occlusion identified by CT angiography (CTA) in anterior circulation stroke, and analyzed the influence of the occlusion site on treatment outcome in relation to other outcome factors. We selected 71 patients from a stroke database collected between June 2007 and December 2011 at our hospital. All of the studied patients had anterior circulation stroke with intracranial occlusion detected by CTA and were treated with intravenous rt-PA. They were divided into two groups according to the site of occlusion along the middle cerebral artery course: proximal (carotid "T", complete M1 and mild M1 occlusions) and distal (M2/M3 occlusions). Treatment effectiveness was assessed by modified Rankin Scale (mRS) at three months, considering a positive outcome a mRS value ≤ 2. Treatment safety was assessed by evaluating the rate of hemorrhagic complications seen on unenhanced CT at 24 hours. Binary logistic regression was performed to evaluate the interaction between occlusion site and other variables such as sex, age, ASPECT score on admission and baseline NIHSS value in determining treatment outcome. The degree of effectiveness and safety differed when considering patients with proximal and distal occlusions. The percentage of successfully treated cases was 28.6% in the first group compared to 72% in the second, and the rate of hemorrhagic complications was 28.6% and 6% respectively. After adjustment for sex, age, ASPECT score on admission and baseline NIHSS value, occlusion site was the only variable significantly influencing treatment safety and, together with baseline NIHSS value, the only valid predictor of treatment effectiveness. We demonstrated a correlation between the site of arterial occlusion and outcome of intravenous thrombolysis. By helping the choice of the best therapeutic strategy depending on the identified occlusion site, CTA could be usefully added to the examinations included in the Stroke Protocol for the baseline evaluation of patients with suspected acute stroke.

Evaluation protocol for amusia - portuguese sample

Amusia is a disorder that affects the processing of music. Part of this processing happens in the primary auditory cortex. The study of this condition allows us to evaluate the central auditory pathways. ObjectiveTo explore the diagnostic evaluation tests of amusia. MethodThe authors propose an evaluation protocol for patients with suspected amusia (after brain injury or complaints of poor musical perception), in parallel with the assessment of central auditory processing, already implemented in the department. The Montreal Evaluation of Battery of amusia was the basis for the selection of the tests. From this comprehensive battery of tests we selected some of the musical examples to evaluate different musical aspects, including memory and perception of music, ability concerning musical recognition and discrimination. In terms of memory there is a test for assessing delayed memory, adapted to the Portuguese culture. Prospective study. Results and ConclusionsAlthough still experimental, with the possibility of adjustments in the assessment, we believe that this assessment, combined with the study of central auditory processing, will allow us to understand some central lesions, congenital or acquired hearing perception limitations.

Psychological evaluation and follow-up in liver transplantation.

An increasingly number of transplant centers have integrated a psychological assessment within their protocol for evaluation of patients being considered for transplantation. This paper highlights the psychological criteria for inclusion or exclusion for listing, briefly discusses the psychological dynamics of patients, and addresses possible psychotherapy and pharmacological therapy, before and after transplant.

Predicting the Success of Endoscopic Transpapillary Gallbladder Drainage for Patients with Acute Cholecystitis During Pretreatment Evaluation

Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported to be an effective treatment for acute cholecystitis, technical difficulties have precluded more widespread use of this technique. Case evaluations that can predict the occurrence of such difficulties should increase the acceptance of ETGBD for acute cholecystitis treatment. To establish a pretreatment evaluation protocol for patients with acute cholecystitis. Eleven patients with acute cholecystitis who received ETGBD in 2003 or 2004 were enrolled in the present retrospective study. The frequency of success, complications and overall effectiveness of ETGBD for treatment of cholecystitis were measured. Factors that could affect ETGBD success, including clinical and laboratory parameters, and gallbladder ultrasonograms, were also evaluated. ETGBD was successful in seven of 11 patients (success rate 63.6%). All seven patients who underwent ETGBD successfully were afebrile and asymptomatic within a few days. No clinical or laboratory variables were significantly associated with the success of ETGBD. In contrast, ultrasonographic measures of gallbladder minor-axis length and wall thickness in successful cases were significantly shorter (27.4 mm versus 38.0 mm; P=0.008) and thinner (4.2 mm versus 9.0 mm; P=0.041) relative to unsuccessful cases. Ultrasonographic measures of gallbladder minor-axis length and wall thickness can serve as important predictors of ETGBD technical difficulties during pretreatment evaluation of patients with acute cholecystitis.

Optimization of FDG-PET/CT imaging protocol for evaluation of patients with primary and metastatic liver disease.

BackgroundAccurate determination of the extrahepatic extent and intrahepatic distribution of disease is very important in patients with primary and metastatic liver disease for deciding whether a patient receives potentially curable surgery or palliative treatment. Our objective was to evaluate the efficacy of delayed phase FDG-PET/CT imaging in lesion detection and to define its clinical impact compared to triple-phase contrast enhanced CT (CECT).Methods30 patients underwent delayed phase FDG-PET/CT imaging (90 min whole body scan followed by a delayed abdominal scan at 120 min). Maximum standard uptake values (SUVs) and SUV ratios between tumor and normal liver parenchyma (T/N) were evaluated. In addition, comparison was made to CECT obtained within 10 days of the FDG-PET/CT to evaluate for lesion concordance within individual liver segments (Couinaud designation).ResultsSites of primary malignancies included: colorectal (19), breast (3), pancreas (2), lung (2), carcinoid (2), cholangiocarcinoma (1), and hepatocellular carcinoma (1). There was a significant increase in SUV value of liver lesions between early and delayed acquisition (P < 0.001). Although there was not a significant reduction in liver background activity between the two studies, there was a strong increase in T/N ratio (P < 0.001) allowing better lesion detection by visual inspection. New lesions were identified in 5 of the 30 patients, which were not appreciated on the early scan. Delayed phase FDG-PET/CT identified one lesion which was not present on the corresponding CECT. Delayed phase FDG-PET/CT revealed extrahepatic sites of metastases not appreciated on CECT in 6 patients.ConclusionDelayed phase FDG-PET/CT protocol improved lesion detectability in primary and metastatic liver disease, revealing new lesions in 17% of the patients. Moreover, FDG-PET/CT identified extrahepatic disease not seen on CECT in 20% of the patients.

Landmark Clinical Trial in Swallowing Results Released

Landmark Clinical Trial in Swallowing Results Released

Application of a protocol for the detection of disorders of sialic acid metabolism to 124 high-risk Brazilian patients

Lysosomal storage disorders (LSD) present great clinical variability. Included in this group are sialic acid metabolism disorders (SAMD). In the present study, we describe the application of a 3-step protocol for the diagnosis of SAMD, including (1). oligosaccharide and sialyloligosaccharide chromatography; (2). quantitative determination of sialic acid; and (3). measurement of neuraminidase activity. Application of our protocol to 124 individuals at risk for SAMD led to the diagnosis of five affected patients, two with type I sialidosis, one with type II sialidosis, and two with galactosialidosis. Due to its simplicity and efficiency, we propose the use of this protocol for the diagnostic evaluation of patients with suspected SAMD, which could be specially useful to non-specialized laboratories and to services located in developing countries.

Intégration de lˈévaluation nutritionnelle à lˈexamen médicallors de lˈadmission à lˈhôpital

Protein-calorie malnutrition (PCM) negatively affects the healing process, morbidity and mortality as well as medical costs. The nutritional assessment at hospital admission is essential in order to determine the need for nutritional intervention and for optimizing it. Based on clinical evolution, the nutritional evaluation assesses the adequacy of energy intake to metabolic requirements, energy reserves and bodily functions. A global evaluation of nutritional status aims at defining whether the patient is well-nourished, moderately or severely malnourished and whether the causes of PCM will disappear, improve or worsen. A global nutritional evaluation should also define the healing potential in order to decide if the nutritional intervention should be immediate or delayed, maximal or partial. The diagnosis and quantification of PCM is based on several parameters determined by clinical, biochemical and functional tests. This review summarizes the clinically relevant methodologies and proposes a protocol for the nutritional evaluation of patients at hospital admission.

The impact of the development of a program to reduce urgent (off-hours) venous duplex ultrasound scan studies

Objective: The purpose of this study was to develop a protocol for evaluation of patients suspected of having deep venous thrombosis (DVT) who came to the hospital after normal noninvasive vascular laboratory (NIVL) working hours in an attempt to both retain registered vascular therapists and provide excellent patient care. Methods: We developed a protocol for evaluation of patients suspected of having DVT who were seen at night after normal NIVL working hours (8 am to 9 pm). After exclusion of those with contraindications, all eligible patients either received low-molecular weight heparin (LMWH; 1 mg/kg) and were sent home or were placed at bedrest in the emergency department until the NIVL opened the following morning. Those sent home were given maps to the NIVL and told what time to report. Parameters examined were numbers of after-hours venous duplex ultrasonography (VDU) studies, patient morbidity and mortality, and RVT retention. We compared results from October 1, 1997, through September 30, 1998, the year before the program started, with those from October 1, 1998, through September 30, 2000, the 2 years after program implementation. Data were compared with χ 2 analysis. Results: During the study period, 161 patients suspected of having DVT were seen at the NIVL after hours and were deferred for study until the morning. Eighty-eight patients received prophylactic LMWH and were sent home, and 73 patients were placed in observation. All had VDUs the next morning at 8 am. No deaths, pulmonary emboli, or immediate complications of anticoagulation therapy were seen. After implementation, we noted an 89% reduction in after-hours VDU studies. Before program implementation, four RVTs resigned during an 18-month period because of issues relating to excessive call. From 1998 through 2000, the NIVL had 100% retention of its nine RVTs. Conclusion: The development of the LMWH program has reduced after-hours VDUs by 89% without causing patient morbidity or mortality. Retention of RVTs has been 100% since program implementation. (J Vasc Surg 2002;36:132-6.)

The Widened Mediastinum

Little attention has been given to the sequential assessment and management of a cohort of patients with potential aortic disruption manifested by a widened mediastinum. These patients often require diagnostic peritoneal lavage (DPL), cranial computed tomography (CCT) scan, thoracic aortography, and multiple operations. We surveyed 408 patients with a widened mediastinum who underwent aortography from 1981 to 1989 to determine priorities of management. Multisystem injuries were common with 278 (68%) and 72 (18%) of patients requiring DPL and celiotomy, respectively. Central nervous system (CNS) injury occurred in 276 (68%) patients, and orthopedic injuries were present in 162 (40%). There were 35 thoracic aortic injuries and 17 branch injuries with 15 deaths (11 aortic, 4 branch). Mortality primarily was attributed to hemorrhage, neurologic injuries, and multisystem organ failure. We evaluated the sequence of diagnostic and therapeutic interventions to determine possible sequence errors and 98% of patients had no errors identified. Based on this experience, we have formulated a management protocol for evaluation of patients with multiple injuries and a widened mediastinum.